City of Raleigh Claim and Notice of Injury/Property Damage
Revised 02/2016
This form is designed as a notice of personal injury and/or property damage that involved the City of Raleigh.
Name:
________________________________________________________________________________
First Middle Last
Address: ______________________________________________________________________________
City ___________________________ State _________________ Zip Code ________________________
Telep
hone: Home: __________________________ Business or Cell: ____________________________
Email: __
______________________________________________________________________________
In support of this claim, the following facts are set forth:
1. Date of I
ncident: ____________________________________Time:________________________
2. Exact lo
cation where injury/property damage occurred:
_____________________________________________________________________________
3. Facts con
cerning how and circumstances under which injury/damage occurred. Describe alleged defect.
(If additional space is needed, attach supplementary sheet)
_______________________________________________________________________________
_______________________________________________________________________________
________________
_______________________________________________________________
Was ther
e a defect in a street, sidewalk, or other public place in the City of Raleigh? ___________
How long has defective condition existed? ____________________________________________
Was City notified of defect causing this accident prior to the accident? ______________________
If so, when and by whom? _________________________________________________________
4. Perso
ns who witnessed incident and/or have knowledge of alleged defect.
Name/Address/Phone#
________________
___________ _____________________________________ _____________
5. Provide
name(s) of any City of Raleigh department or person with whom you have been in contact
regarding this incident and/or police report number:
_______________________________________________________________________________
6. Were any
injuries sustained? _____________ Personal Injury (if known) $___________________
Describ
e injuries: ________________________________________________________________
7. Was any
property damaged? _____________ Property Damage (if known) $ _________________
What pr
operty was damaged? ______________________________________________________
I acknow
ledge that the above information is true and accurate.
Claima
nt Signature: _______________________________ Date: _______________________
Return to:
City of Raleigh
Risk Management Division
P. O. Box 590
Direct: 919-996-224
0
FAX:
919-996 -7228
E-mail: riskmanagement@raleighnc.gov
Ralei
gh, NC 27602
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