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
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Last
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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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STATEMENT OF ACCIDENT - PLEASE ANSWER EVERY QUESTION
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Accident Date
April 2024
Sun
Mon
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Wed
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Sat
14
31
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15
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19
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Jan
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Today
Clear
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Accident Time
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Accident Location
City
County
State
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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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DESCRIPTION OF PROPERTY DAMAGE
Make of Vehicle
Model
VIN
License Plate
Year
Registered Owner Name
Phone
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Owner's Address
City
State
Zip
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Driver's Name
Date of Birth
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Driver's Address
Phone
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City
State
Zip
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Insurance Company
Policy #
Has a claim been filed with your insurance company?
No
Yes
Claim #
Phone
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Estimated cost of vehicle repairs
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Where is the vehicle currently located?
Describe property damaged (if other than auto):
DESCRIPTION OF PERSONAL INJURY
Name of Injured Person
Date of Birth
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Injured Person’s Address
Phone
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City
State
Zip
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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
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WITNESSES
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
Click 'Print' If you would like a copy of the Notice of Claim form. You must click Print BEFORE you click Submit
Click Submit to send the Notice of Claim form to City of Arlington
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