This form should be completed to report a claim against the City involving bodily injury or auto/property damage. Please complete, sign, and submit this form to the City within 30 days of the incident. The claim will be investigated by an adjuster to determine liability. If a question does not apply, please indicate 'n/a' in the space provided. If the claimant does not know the answer to a question, please put 'unknown' in the space provided.
A completed form may be faxed to Human Resources/Risk Management at 817-222-7740, but the signed original must be mailed or hand delivered to 5024 Broadway Avenue, Haltom City, TX 76117 as soon as possible. If you have questions or need help completing this form, please contact Human Resources/Risk Management at 817-222-7742.