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GENERAL
DAMAGE 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_____________
INCIDENT
DESCRIPTION
Date_____________________ Time__________________________
(a.m.) (p.m.)
Location____________________________________________________________________
Weather
Conditions___________________________________________________________
Condition
of Street/Sidewalk____________________________________________________
Describe
What Happened______________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
PERSONS
INJURED
Was
anyone 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
_______________________Home Phone___________________________________
Address____________________________________________________________________
Name
______________________ Home Phone____________________________________
Address________________________________________________________________________
CITY EMPLOYEE INVOLVED
Name any City employee who witnessed
this occurrence, investigated it, or that
you notified:
Name
__________________________________________________________________________
Department _____________________________________________________________________
How
are they involved?_____________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
INSURANCE
Do
you have insurance to cover your loss? _____________________________________________
Name
of Insurance Company_________________________________________________________
Type
of Coverage___________________________________________________________________
PROPERTY DAMAGE
Describe
any damage to your personal property, including
the date it was
purchased and it's estimated replacement
cost.__________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Why
do you feel the City was responsible for
this occurrence?______________________________
________________________________________________________________
_______________________________________________________________
Signature_________________________________________________________________________
Date_____________________________________________________________________________
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