Fillable CITY OF KILLEEN NOTICE OF CLAIM (City of Killeen, Texas)

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CITY OF KILLEEN NOTICE OF CLAIM (City of Killeen, Texas)

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The CITY OF KILLEEN NOTICE OF CLAIM (City of Killeen, Texas) form is 2 pages long and contains:

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  • 4 check-boxes
  • 14 other fields

Country of origin: US
File type: PDF

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CITY OF KILLEEN NOTICE OF CLAIM
Receipt of this form is not an admission or acceptance of liability by the City of Killeen.
Name: ____________________________________________________________________________________
Address: ___________________________________________________________________________
Phone Number: _____________________ Email Address: __________________________________
Type of incident: Auto Property Personal Injury Other: __________________
If personal injury, who was injured? ______________________________________________
Describe incident in detail. (Use additional paper if needed).
Da
te when incident happened? ________________________________________________________
Address or location where incident happened? ___________________________________________
Police report number (if known): _______________________________________________________
Rev Jun 2020
1 | Page
Names, addresses and phone numbers of any witnesses:
1._____________________________________________________________________________
2._____________________________________________________________________________
3._____________________________________________________________________________
ATTACH UP TO THREE REPAIR ESTIMATES AND PHOTOS OF AUTO OR PROPERTY DAMAGE.
ATTACH ALL AVAILABLE MEDICAL BILLS FOR INJURIES.
ALL OF THE STATEMENTS MADE IN THIS NOTICE OF CLAIM
FORM ARE TRUE AND CORRECT TO THE
BEST OF MY KNOWLEDGE.
__________
________________________________ ______________________________
Signature Date
INSTRUCTIONS:
Complete both page of the Notice of Claim form.
Be sure to sign and date page 2 of this form.
Subm
it completed form and supporting documents via one of the following options:
Email: claims@killeentexas.gov
Mail: Human Resources, Attention: Claims Specialist
PO Box 1329, Killeen, TX 76540
Hand Deliver: Human Resources, Attention: Claims Specialist
718 N 2nd Street, Building H, Suite B, Killeen, TX 76541
Fax: 254-501-7688
Questions: 254-501-7684
Receipt of this form is not an admission or acceptance of liability by the City of Killeen.
Rev Jun 2020
2 | Page
*Per Texas Tort Claims Act, Chapter 101 all documents pertaining to a claim against the City of
Killeen must be submitted no later than six (6) months from the date of incident.
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CITY OF KILLEEN NOTICE OF CLAIM (City of Killeen, Texas)

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Completed 1 February 2021

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