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CLAIM FORM
Date:
CLAIMANT INFORMATION:
Name:
Address:
Tel. Number: Cell Number:
Email address:
INCIDENT/LOSS INFORMATION
Date of Incident/Loss:
L
ocation of Incident:
D
escription of Incident – Explain what occurred giving rise to claim:
[Attach additional pages if necessary, including photographs, estimates, etc.]
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Founded 1639
Alleged Damages Describe damages alleged to have been incurred as a result of this incident:
[Attach copies of all estimates, invoices and other items documenting amount of alleged loss]
I
hereby attest to the truth, accuracy and completeness of the information contained herein or as may be
attached or supplemented.
I understand that any false statement herein or within the materials I have submitted, which I know or do
not believe to be true and which are intended to mislead a public official in the performance of their duty is
punishable by law (see CGS Sect. 53a-157b).
I d
eclare under the penalty of false statement that the information submitted is true and correct. Dated in
, Connecticut this day of , .
Signature of Claimant
NOTICE:
The City of Milford is insured through Connecticut Interlocal Risk Management Agency (CIRMA).
All claims are forwarded to CIRMA, which investigates each claim. A representative from CIRMA will
provide you with contact information and any follow up communications with regard to your claim
should be directed to CIRMA.
Please note that the filing of this Claim Form does not constitute a waiver of the claimant’s responsibility to
comply with any and all filing or notice requirements that might exist independent of the filing of this
Claim Form.
Please also note that the acceptance and processing of this Claim Form does not constitute an
acknowledgement by the City of liability or an obligation to make any payment for the asserted claim.
Furthermore, the City is entitled to assert a number of special defenses to any claim for damages, as
allowed by the law and statutes of Connecticut. These defenses may serve to reduce or remove any liability
that the City might otherwise have. The City of Milford, in accepting this Claim Form, does not consent to
waive any of these defenses.
MAIL OR HAND DELIVER COMPLETED CLAIM FORM ALONG WITH COPIES OF ALL
PHOTOGRAPHS, ESTIMATES, INVOICES AND OTHER ITEMS OF PROOF OF THE AMOUNT
OF THE ALLEGED LOSS TO:
City Clerk
City of Milford
110 River Street
Milford, CT 06460
2 of 2
January
2019
1
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