City of Salisbury MD

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Submit a Claim

Submit a Claim – Insurance/Liability

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

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.

Add a Picture

Drop files here or

Max. file size: 256 MB.

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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