Tort Claims

Describe how the accidence or occurrence happened. If a diagram will assist your explanation, you may upload a diagram below.

If there were any Municipal Employees whom you claim were at fault, please identify them here, including any information that will assist in identifying and locating them.

State in detail each and every negligent or wrongful act of the Municipality and Municipal employees who caused your damage(s).

State the names and addresses of al witnesses to the accident or occurrence.

State the names of all Police Officers who investigated the incident.

Describe your injuries resulting from this accident or occurrence.

Describe the injuries believed to be permanent.

For each hospital, doctor, or other practitioner rendering treatment or diagnostic service, state the following information: (1) Name of Hospital/Doctor/Facility (2) Address (3) Dates of Treatment or Services (4) Amount of Charges to Date (5) Amount Paid or Payable by Other Sources Such As Insurance

Please explain the following in your claim of loss of wages or income as a result of the injury? (1) Name of Employer(s) (2) Address of Employer(s) (3) Your Occupation & Title (4) Date of Initial Employment (5) Pay Rate (6) Dates of Absence from Work (7) Total Lost Wages to Date (8) Date of Return or Expected Date of Return

Set forth any and all other losses or damages claimed by you.

Set forth in detail the description of the property damage, the loss claimed by you for property damage, as well as all other items of loss of damages by you and the method by which you made the calculation(s).

Please describe in detail any claims against anyone else for any of the losses or expenses associated with this notice?

For each such policy, state the names and addresses of the insurance company, policy number and benefits paid or payable.

Set forth the details of the agreement to receive any money from anyone for the damages claimed.