* Required field
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*First |
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M.I. |
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*Address |
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Apt. |
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*City |
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*State |
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*Zip |
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*Phone |
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Alternate Phone |
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Date of Birth |
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Email |
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*Accident Date |
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18 | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
19 | 8 | 9 | 10 | 11 | 12 | 13 | 14 |
20 | 15 | 16 | 17 | 18 | 19 | 20 | 21 |
21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 |
22 | 29 | 30 | 31 | 1 | 2 | 3 | 4 |
23 | 5 | 6 | 7 | 8 | 9 | 10 | 11 |
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Jan | Feb | Mar | Apr |
May | Jun | Jul | Aug |
Sep | Oct | Nov | Dec |
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*Accident Time |
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Accident Location |
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City |
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County |
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*Please explain what happened and why you feel the City of Arlington is responsible for the injuries and/or damages
sustained as a result of this incident. |
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Make of Vehicle |
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Model |
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VIN |
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License Plate |
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Year |
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Registered Owner Name |
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Phone |
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Owner's Address |
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City |
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State |
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Zip |
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Driver's Name |
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Date of Birth |
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Driver's Address |
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Phone |
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City |
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State |
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Zip |
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Insurance Company |
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Policy # |
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Has a claim been filed with your insurance company? |
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Claim # |
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Phone |
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Estimated cost of vehicle repairs |
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Where is the vehicle currently located? |
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Describe property damaged (if other than auto): |
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Name of Injured Person |
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Date of Birth |
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Injured Person’s Address |
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Phone |
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City |
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State |
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Zip |
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How did the personal injury occur? |
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Describe injuries, treatment, and give name and phone number of physician(s) |
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The following are needed to evaluate your claim. Please retain these documents until you are contacted by an adjuster:
- Repair bills, receipts or two estimates of damage
- Photos of damage, if available
- All medical reports, medical bills and lost wage statements
- Any other documents to support your claim
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Name |
Address |
Phone |
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Name |
Address |
Phone |
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I attest that the information provided herein is true, accurate, and complete to the best of my knowledge and belief. |
Name of person completing claim form |
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The submitted code is incorrect |
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Show another code | |
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Please note: If the code shown above or other boxes are not working: |
- Computer cookies must be enabled from your computer in order to submit this form.
A computer cookie, also referred to as an "HTTP cookie," is a small text file that contains a unique ID tag, placed on the user's computer by a website.
- If you're still not able to submit after enabling cookies, please contact us by e-mail at citysecretary@arlingtontx.gov or call 817-459-6186.
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Click 'Print' If you would like a copy of the Notice of Claim form. You must click Print BEFORE you click Submit |
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Click Submit to send the Notice of Claim form to City of Arlington |
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