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Claim Form

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CLAIM FORM
DATE:
DATE:
FIRST NAME:
LAST NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
WORK/CELL PHONE:
DATE/TIME OF INCIDENT
DATE/TIME OF INCIDENT
DATE/TIME OF INCIDENT
PLACE OF INCIDENT:
CITY:
STATE:
ZIP CODE:
PLEASE DESCRIBE, IN DETAIL, THE NATURE OF YOUR CLAIM AND WHAT REIMBURSEMENT YOU ARE SEEKING.
ATTACH EXTRA PAGES AND PHOTOS HERE
PLEASE ATTACH A COPY OF THE BILL/ESTIMATE FOR YOUR DAMAGES:
DO YOU HAVE AUTOMOBILE INSURANCE?
1. YES
2. NO
IF YOU ANSWERED YES, PLEASE ATTACH A COPY OF YOUR INSURANCE CARD.
DID YOU FILE AN INSURANCE CLAIM?
1. YES
2. NO
IF YOU ANSWERED YES, WHAT IS YOUR DEDUCTIBLE?
THE CITY OF NORWOOD IN NO WAY ADMITS ANY LIABILITY FOR YOUR CLAIMED DAMAGES AND STRONGLY SUGGESTS THAT YOU SUBMIT YOUR CLAIM TO YOUR INSURANCE COMPANY.
PLEASE RETURN TO:
NORWOOD CITY COUNCIL
CITY OF NORWOOD
ROOM 205
4645 MONTGOMERY RD
NORWOOD, OH 45212
FAX 513-458-4595

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