AFFIDAVIT OF INSURANCE
If uninsured, please complete the following:
I, , swear or affirm that I do not have Property insurance. Alternatively, I
swear or affirm that I/my company is self-insured.
UNINSURED CLAIMANT SIGNATURE: ____________________________ DATE: __________
If insured, please complete the following:
PROPERTY INSURANCE COMPANY:
PROPERTY INSURANCE POLICY NUMBER:
Ohio Revised Code, Section 2744.05 outlines limitations of damages awarded for claims against political
subdivisions. If a claimant receives or is entitled to receive benefits from insurance policy or policies,
that amount will be deducted from any award the political subdivision may consider paying. This
includes Medicaid, Medicare and Property insurance policies.
**You MUST file a claim with your insurance company prior to filing a claim with the City of Springfield.
Documentation of filing of a claim with your insurance company must be attached to this Claim Packet.
You must also submit a copy of your Property Insurance Declarations Page with this Claim Packet.**
FURTHERMORE, WITH RESPECT TO ANY DAMAGES ALLEGED IN THIS CLAIM PACKET, CLAIMANT MUST BE
MADE AWARE THAT, BY STATUTE, THE CITY OF SPRINGFIELD, OHIO MAINTAINS SIGNIFICANT IMMUNITY
FROM LIABILITY FOR DAMAGES OF THIS NATURE. OHIO REVISED CODE SECTION 2744.05 ADDRESSES THESE
IMMUNITIES. IN SHORT, CLAIMANT MUST PROVE THAT THE CITY OF SPRINGFIELD WAS NEGLIGENT OR
RECKLESS IN THEIR ACTIONS. IF THE CLAIMANT CANNOT PROVE, THROUGH THIS CLAIM PACKET, NOR THE
CITY CAN FIND RECORDS INDICATING NEGLIGENCE OR RECKLESS BEHAVIOUR, THE CITY WILL MAINTAIN
IMMUNITY AND WILL BE UNABLE TO PAY THE REQUESTED CLAIM.
I state that I am not entitled to receive any additional reimbursement for these damages from any
other source other than the City of Springfield, and that the claim(s) arising from these damages are a
direct result of this incident.
I, , attest that by signing below, I have read and understand the
requirements for submission of a claim to the City of Springfield.
CLAIMANTS SIGNATURE: DATE: _________
Send completed form with supporting documentation to law@springfieldohio.gov
Completed Claim Form Photos of Damage Two Estimates Completed W9 Form
Insurance Declarations Page Documentation a Claim has been filed with Insurance
click to sign
signature
click to edit
click to sign
signature
click to edit