Submit a Claim

Submit a Claim - Insurance/Liability

Today's Date*
MM slash DD slash YYYY
Name*
First Last
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Email Address
Phone*
Type of Claim being made (please check all appropriate boxes):*
- Vehicle Damage
- Property Damage
- Personal Injury
Date of Incident*
MM slash DD slash YYYY
Time of Incident*
What was the weather conditions at time of the incident? (please check all that apply)*
- Sunny
- Raining
- Snowing
- Ice
- Fog
Exact Location of Incident*
Give a brief description of the incident. City staff will contact you once your claim has been received.*
Vehicle Year*
Vehicle Make*
Vehicle Model*
Vehicle Color*
Vehicle Tag Number*
Did you report this incident to the Police?*
- Yes
- No
Police Report Number*
Do you have insurance to cover the loss?*
- Yes
- No
Did you file a claim with your insurance company regarding this loss?*
- Yes
- No
Claim Number*
Insurance Adjuster's Name*
Contact Information of your Insurance Company*
Insurance Policy Number*
Did you receive medical attention?*
- Yes
- No
Were you treated at the scene or transported to medical facility?*
- Treated at scene
- Transported to medical facility
Were you transported by:*
- Self/Family Member
- Friend
- EMS Unit
Was anyone else injured at this incident?*
- Yes
- No
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Did anyone witness this incident or injury?*
- Yes
- No
Witness Name #1*
First Last
Witness Address*
Street Address Address Line 2 City State ZIP Code
Witness Phone*
Was there an additional witness?*
- Yes
- No
Witness Name #2*
First Last
Witness Address*
Street Address Address Line 2 City State ZIP Code
Witness Phone*
Claim attachments (repair estimates, invoices, etc.)
Drop files here or

Max. file size: 256 MB, Max. files: 10.
Add a Picture
Drop files here or

Max. file size: 256 MB, Max. files: 10.
Consent*
By typing my name in the below field, I hereby declare that the details provided in this claim are true and correct to the best of my knowledge.
Enter Full Name to Submit Form*
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Name
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