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  1. City of North Miami Risk Management Division

  3. The following information must be completed with the utmost accuracy to the best of your knowledge. Complete information will aid in expediting the process. Submission of a claim does not guarantee payment by the City.
  4. General Information on Claimant / Incident
  5. Complete this Section for Automobile Collission
  6. City Vehicle
  7. Your Vehicle Involved
  8. 2nd Auto
  9. 3rd Auto
  10. Injured Party's Information
  11. Bodily Injury
  12. Your Vehicle Damage /Loss
  13. Police Report
  14. Ambulance
  15. General Liability
    Bodily Injury from an Incident (other than Auto)
  16. Was Scene
  17. Photos Taken*
  18. Area Clean*
  19. Area Dry*
  20. Area well lighted*
  21. level Surface
  22. Cracks or Breaks*
  23. Slippery*
  24. Injured Person's Shoes
  25. High Heel*
  26. Low Heel*
  27. Floppy Type*
  28. Flat Sole*
  29. Using Cane or Walker*
  30. Was injured Wearing Glasses*
  31. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  32. The information on this from is confidential information under Florida Statute 768.28.

  33. Person(s) who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, dies a statement of claim containing any false or misleading information, commits insurance fraud, punishable as provided in FS. 817.234.

  34. Leave This Blank:

  35. This field is not part of the form submission.