Fillable CITY OF SPRINGFIELD, OHIO Vehicle Damage Claim Statement (City Of Springfield, Ohio)

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CITY OF SPRINGFIELD, OHIO Vehicle Damage Claim Statement (City Of Springfield, Ohio)

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The CITY OF SPRINGFIELD, OHIO Vehicle Damage Claim Statement (City Of Springfield, Ohio) form is 2 pages long and contains:

  • 2 signatures
  • 6 check-boxes
  • 38 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City Of Springfield, Ohio

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CITY OF SPRINGFIELD, OHIO
Vehicle Damage Claim Statement Form
NAME
BIRTH DATE
HOME PHONE
CELL PHONE
STREET ADDRESS
CITY
STATE
ZIPCODE
EMAIL ADDRESS
EMPLOYER NAME
VEHICLE MAKE/MODEL
YEAR
MILEAGE
OWNER’S NAME:
OWNER’S ADDRESS AND TELEPHONE:
DRIVER’S NAME:
DRIVER’S ADDRESS AND TELEPHONE:
# OF PEOPLE IN VEHICLE:
PASSENGER NAMES:
COST FOR REPAIR ESTIMATE 1 (Attach a copy):
COST FOR REPAIR ESTIMATE 2 (Attach a copy):
DESCRIPTION OF INCIDENT
If you have photos of the damage that resulted, please attach them to this form.
INCIDENT DATE:
INCIDENT TIME:
INCIDENT LOCATION:
CITY DEPARTMENT INVOLVED, IF ANY:
NAME OF CITY EMPLOYEE INVOLVED, IF ANY:
POLICE REPORT MADE?
YES:
☐
NO:
☐
POLICE REPORT #:
If no, why?
DESCRIPTION: (Please be as specific as possible in your description. Include as much detail as possible, such as
how fast you were going, in what lane, etc. If you require more space, please attach a separate sheet.)
AFFIDAVIT OF INSURANCE
If uninsured, please complete the following:
I, , swear or affirm that I do not have Auto insurance. Alternatively, I
swear or affirm that I/my company is self-insured.
UNINSURED CLAIMANT SIGNATURE: ____________________________ DATE: __________
If insured, please complete the following:
AUTO INSURANCE COMPANY:
AUTO 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 Auto 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 Auto 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
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CITY OF SPRINGFIELD, OHIO Vehicle Damage Claim Statement (City Of Springfield, Ohio)

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Completed 16 July 2020

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