CHAPTER X OF THE CHARTER OF THE CITY OF ARLINGTON REQUIRES WRITTEN NOTICE BEFORE ANY CLAIM FOR PERSONAL INJURY OR PROPERTY DAMAGE MAY BE CONSIDERED. THIS FORM MUST BE COMPLETED AND FILED WITHIN 180 DAYS OF THE INJURY OR DAMAGE WITH:
City of Arlington
P.O. Box 90231-MS 01-0360
101 West Abram Street
Arlington, TX 76004-3231
ALL QUESTIONS REGARDING YOUR CLAIM SHOULD BE DIRECTED TO THE HUMAN RESOURCES DEPARTMENT AT
817-459-6310.
IF A MEETING IS NECESSARY, APPOINTMENTS ARE REQUESTED TO ENSURE THE APPROPRIATE STAFF IS AVAILABLE TO ASSIST YOU.
CLAIMANT INFORMATION
* Required field
*Last
*First
M.I.
*Address
Apt.
*City
*State
v
*Zip
*Phone
Alternate Phone
Date of Birth
Email

STATEMENT OF ACCIDENT - PLEASE ANSWER EVERY QUESTION
*Accident Date
v
*Accident Time
+
-
Accident Location
City
County
State
v
*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.

DESCRIPTION OF PROPERTY DAMAGE
Make of Vehicle
Model
VIN
License Plate
Year
Registered Owner Name
Phone
Owner's Address
City
State
v
Zip
Driver's Name
Date of Birth
Driver's Address
Phone
City
State
v
Zip
Insurance Company
Policy #
Has a claim been filed with your insurance company?
Claim #
Phone
Estimated cost of vehicle repairs
Where is the vehicle currently located?
Describe property damaged (if other than auto):

DESCRIPTION OF PERSONAL INJURY
Name of Injured Person
Date of Birth
Injured Person’s Address
Phone
City
State
v
Zip
How did the personal injury occur?
Describe injuries, treatment, and give name and phone number of physician(s)

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
LIST OCCUPANTS OF YOUR AUTOMOBILE
 
Name Address Phone
WITNESSES
Name Address Phone

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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