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2. 
3. 
   
   
   NOTICE OF INJURY OR PROPERTY DAMAGE
5. 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.
7. General Information on Claimant / Incident
9. Name*
10. Email Address*
12. Address*
14. City*
15. State*
16. Zip Code*
18. Cell Number*
19. Work Number
20. Home Number
22. Date of Birth*
    Date of Birth
23. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident
25. Location of Incident*
27. Weather Conditions*
29. Detailed account of incident
    (State your claim; provide all supporting information available)*
31. Name of person completing form *
32. Relationship to Claimant(s)*
34. Date*
    Date
36. Complete this Section for Automobile Collission
38. City Vehicle
40. Vehicle #*
41. Yr/Make/Model*
42. City Driver*
43. Driver License #*
45. Your Vehicle Involved
47. Tag #*
48. Yr/Make/Model*
49. Color*
50. Driver*
52. License #*
53. Address*
55. 2nd Auto
57. Tag #
58. Yr/Make/Model
59. Color
60. Driver
62. License #
63. Address
65. 3rd Auto
67. Tag #
68. Yr/Maker/Model
69. Color
70. Driver
72. License #
73. Address
77. Auto Owner
78. Driver
79. Auto Insurer Policy #
81. 1. Passenger Name
82. Phone Number(s)
83. Address
85. 2. Passenger Name
86. Phone Numbe(s)
87. Address
89. Injured Party's Information
91. Bodily Injury
93. Name
94. Email Address
96. Address
97. City
98. State and Zip Code
100. Phone Number
102. Describe Injury
104. Your Vehicle Damage /Loss
106. Describe Damage
108. Owner's Address
109. City
110. State and Zip Code
112. Phone Number
114. Police Report
115. Department
116. Investigating Officer
118. Ambulance
119. Organization
120. Unit
122. 1. Witness' Name
123. Email Address
125. Address
127. City
128. State
129. Zip Code
131. Phone Number
132. Fax Number
134. 2. Witness' Name
135. Email Address
137. Address
139. City
140. State
141. Zip Code
143. Phone Number
144. Fax Number
146. State your claim and provide documentation:
     (3 /estimates required for vehicle damage)
148. Auto Collision Diagram (PDF)
     Auto Collision Diagram

     Draw boxes showing City Auto (C), Your Auto (1) and Other Autos (2,3).

149. Upload Auto Collision Diagram
153. General Liability
     Bodily Injury from an Incident (other than Auto)
155. Was Scene
     Examined?*

     1. Yes
     2. No
156. By whom:*
157. Date and Time*
     Date and Time

     Date and Time
159. Photos Taken*

     1. Yes
     2. No
160. Area Clean*

     1. Yes
     2. No
161. Area Dry*

     1. Yes
     2. No
162. Area well lighted*

     1. Yes
     2. No
164. level Surface

     1. Yes
     2. No
165. Cracks or Breaks*

     1. Yes
     2. No
166. Slippery*

     1. Yes
     2. No
168. Describe other hazards:*
170. Injured Person's Shoes
172. High Heel*

     1. Yes
     2. No
173. Low Heel*

     1. Yes
     2. No
174. Floppy Type*

     1. Yes
     2. No
175. Flat Sole*

     1. Yes
     2. No
177. Using Cane or Walker*

     1. Yes

     1. No
178. Was injured Wearing Glasses*

     1. Yes

     1. No
180. 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.

     1. I agree.

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

184. 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.

186. Electronic Signature*
187. Date and Time*
     Date and Time

     Date and Time
Leave This Blank:


189. 1. Receive an email copy of this form.
190. Email address

     This field is not part of the form submission.

191. Submit Submit and Print

* indicates a required field