Fillable CLAIM INSTRUCTIONS FORM Final IPMG (Niles)

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CLAIM INSTRUCTIONS FORM Final IPMG (Niles)

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The CLAIM INSTRUCTIONS FORM Final IPMG (Niles) form is 4 pages long and contains:

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  • 8 check-boxes
  • 78 other fields

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File type: PDF

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1 of 3
VILLAGE OF NILES CLAIM FORM
Section 1: Must be completed by all claimants
Please Print or Type
NAME
TELEPHONE NUMBER
EMAIL ADDRESS
STREET ADDRESS (or location)
CITY
STATE
ZIP CODE
INCIDENT TIME
ADDRESS OF INCIDENT
DETAILED DESCRIPTION OF INCIDENT
POLICE REPORT MADE?
NO
_______
YES
_______
If yes, Police Report #_________________
PICTURES TAKEN?
NO
_______
YES
_______
WITNESS NAME
TELEPHONE NUMBER
RELATIONSHIP
STREET ADDRESS
CITY
STATE
ZIP CODE
WITNESS NAME
TELEPHONE NUMBER
RELATIONSHIP
STREET ADDRESS
CITY
STATE
ZIP CODE
WITNESS NAME
TELEPHONE NUMBER
RELATIONSHIP
STREET ADDRESS
CITY
STATE
ZIP CODE
I hereby attest that the above information is true to the best of my knowledge and belief.
Signature _____________________________________________
Date __________________
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signature
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2 of 3
Section 2:FOR CLAIMS CONCERNING VEHICLE DAMAGE OR AN AUTOMOBILE ACCIDENT
VEHICLE MAKE
YEAR
TYPE
LICENSE NO.
OWNER’S NAME
OWNER’S ADDRESS
DRIVER’S NAME
DRIVER’S ADDRESS
Were you or anyone else injured? Yes ___ No ___
#People in Car:
If yes, complete Personal Injury section.
NAME OF INJURED PERSON 1
ADDRESS
NAME OF INJURED PERSON 2
ADDRESS
NAME OF OTHER VEHICLE OCCUPANT
1
ADDRESS
NAME OF OTHER VEHICLE OCCUPANT
1
ADDRESS
AUTO INSURANCE COMPANY NAME
MEDICAL INSURANCE COMPANY NAME
ESTIMATED REPAIR COST
DEDUCTIBLE AMOUNT
DESCRIBE DAMAGE TO VEHICLE
Section 3:FOR CLAIMS CONCERNING PERSONAL INJURY
NEAREST ADDRESS OF INCIDENT OCCURANCE
NATURE AND EXTENT OF YOUR INJURY
ATTENDING PHYSICIAN NAME
ATTENDING PHYSICIAN ADDRESS
TOTAL TYPE OF MEDICAL EXPENSES TO DATE
TOTAL MEDICAL EXPENSES TO DATE
AMOUNT PAID BY INSURANCE
AMOUNT PAID BY YOU
AMOUNT OF WAGES
LOST
$
$
$
$
HEALTH INSURANCE COMPANY NAME
DEDUCTIBLE AMOUNT
NAME OF HOSPITAL TRANSPORTED TO
$
3 of 3
LIST AND EXPLAIN ANY PHYSICAL DISABILITY
PROVIDE DATE AND NATURE OF ANY PRIOR INJURIES
Section 4: FOR CLAIMS CONCERNING PROPERTY DAMAGE OTHER THAN AUTOMOBILE
CAUSE OF DAMAGE
NAME OF CITY EMPLOYEE CONTACTED
DATE
NAME OF PROPERTY
DEDUCTIBLE AMOUNT
INSURANCE COMPANY
I hereby attest that the above information is true to the best of my knowledge and belief.
Signature _____________________________________________
Date __________________
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CLAIM INSTRUCTIONS FORM Final IPMG (Niles)

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Completed 4 August 2020

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