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SEWER
DAMAGE CLAIM FORM
MAIL TO:
Legal
Department
City Hall
400 Robert D.Ray Drive
Des Moines, IA 50309
PERSONAL
INFORMATION
Name______________________________________________________________________________
Home Address _____________________________________________________________________
Phone ____________________________________________________________________________
Business Address __________________________________________________________________
Phone_____________________________________________________________________________
INCIDENT
DESCRIPTION
When did damage occur? Give full particulars;
date, time of day ____________________________
____________________________________________________________________________________
Where did damage
occur? ___________________________________________________________
____________________________________________________________________________________
Weather conditions
(If raining, indicate duration and amount
of rainfall, if known):_______________
____________________________________________________________________________________
How did damage
occur? _____________________________________________________________
____________________________________________________________________________________
__________________________________________________________________________________
Total amount
of damage claimed $ _______________ (Please
attach Property Inventory form)
Depth of water:
_____________ Type of water (clear, muddy,
etc.):__________________________
Was there sewer
odor in your residence? ______ Do basement
drains contain backwater
valves? _____
Does your home
or basement contain footing drains? _____________________________________
List prior
back-ups or sewer water problems_____________________________________________
_________________________________________________________________________________
__________________________________________________________________________________
Did water seep
through the foundation walls? ____________________________________________
If yes, please describe_______________________________________________________________
_________________________________________________________________________________
When was the
last time your private sewer laterals were
rodded or cleaned? __________________
________________________________________________________________________________
By whom?________________________________________________________________________
________________________________________________________________________________
CITY
EMPLOYEES INVOLVED
Did
you call the City with reference to this
claim? _____ If yes, when?_______________________
________________________________________________________________________________
Did City sewer
crews investigate this claim? ________ Time
and Date of Investigation __________
_________________________________________________________________________________
Names of Employees________________________________________________________________
_________________________________________________________________________________
Substance of
conversation with City crews, if any _________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
INSURANCE
Insurance payments,
if any: $ _________ Date paid: ______________________________________
Insurance Company________________________________________________________________
YOU
MUST COMPLETE THE PROPERTY INVENTORY
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ITEM
(Type,
name, model, year)
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Where
Purchased
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When
Purchased
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Original
Cost
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Discarded
or
Retained
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Replacement
Cost
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Depreciation |
*Actual
Cash
Value
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*Actual
Cash Value -- This is the amount derived
by subtracting the depreciation from the
replacement cost.
Claimant
Signature: __________________________________________
Date:________________
Claimant Signature: __________________________________________
Date:________________
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