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MOTOR
VEHICLE ACCIDENT CLAIM FORM
MAIL
TO:
Legal
Department
City Hall
400 Robert D.Ray Drive
Des Moines, IA 50309
PERSONAL INFORMATION
Your Name____________________________ Date
of Birth___________________________
Home Address_______________________________________________________________
Phone______________________________________________________________________
Business Address____________________________________________________________
Phone______________________________________________________________________
Occupation__________________________________________________________________
Marital Status____________
YOUR MOTOR VEHICLE
Make of Car _______________________________
Year _______ License No.________________
Registered
Owner ___________________________ Address________________________________
Driver
of Car __________________________ Age ____
Address ____________________________
List
damage to your automobile________________________________________________________
Is
car drivable?_____ If not, where is the
car? ___________________________________________
Is
the car insured? __________ Name of
agent_________________________________________
Name
of Insurance Company________________________________________________________
Liability
__________
Comprehensive ______________
Collision______________
PERSONS
INJURED
Was
anyone in your car injured? _____ If so,
please answer the following:
Name
______________________________ Date of Birth_________________________________
Address ________________________________________________________________________
Injuries
_________________________________________________________________________
Where
treated ___________________________________________________________________
Name
______________________________ Date of Birth_________________________________
address ________________________________________________________________________
Injuries
__________________________________________________________________________
Where
treated ____________________________________________________________________
WITNESSES
Name
___________________________________________________________________________
Address _________________________________________________________________________
Phone___________________________________________________________________________
Name
___________________________________________________________________________
Address _________________________________________________________________________
Phone ___________________________________________________________________________
Name
___________________________________________________________________________
Address _________________________________________________________________________
Phone ___________________________________________________________________________
Name ___________________________________________________________________________
Address_________________________________________________________________________
Phone__________________________________________________________________________
CITY EMPLOYEE INVOLVED
Name
of Employee:________________________________________________________________
Type
of Vehicle: __________________________________________________________________
City
Department:__________________________________________________________________
INVESTIGATION
What
police department investigated?________________________________________________
Were
any citations issued? _________________________________________________________
Case No. ________________________________________________________________________
DESCRIPTION
OF ACCIDENT
Date
_______________ Time _______ (a.m., p.m.)
Location __________________________________
Direction
of travel - your vehicle _________ What
street _________________________
Speed _______
Direction
of travel - other vehicle _________ What
street _________________________
Speed _______
Where
was other vehicle when you first saw it?___________________________________________
Where
was your vehicle at that time?___________________________________________________
NARRATIVE
DESCRIPTION OF ACCIDENT
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Who
do you think was at fault and why?_________________________________________________
__________________________________________________________________________________
DIAGRAM
Make
a rough diagram. Show City vehicle as No.
1, your car as No. 2, etc.
THIS
REPORT SHOULD BE SIGNED BY BOTH THE OWNER
AND THE DRIVER.
Owner
Signature: _______________________________________________
Date _________________
Driver
Signature: _______________________________________________
Date _________________
*****
PLEASE SUBMIT TWO ITEMIZED ESTIMATES FOR
REPAIRS *****
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