Created November 10 2015 S:\FORMS\Risk Management\General Liability Claim Form.docx
Ann Frydendall | MICROSOFT
General Liability Claim Form
1. Complete this form in its entirety. Be thorough and specific.
2. Attach supporting documents (pictures, correspondence, and/or witness statements).
3. Attach insurance agent or attorney name and contact information, if applicable.
4. Sign and date form.
5. Submit or Mail (see address below) to City of Veneta Attn: Risk Management.
Date of Incident ___________________________________________________________________
Person Making Claim ___________________________________________________________________
Address of Person Making Claim _______________________________________________________
Phone # of Person Making Claim _______________________________________________________
Descripon of Incident __________________________________________________________________
_____________________________________________________________________________________
Describe Injury or Property Damage _______________________________________________________
_____________________________________________________________________________________
Locaon of Incident ___________________________________________________________________
Witnesses (Include contact informaon) _________________________________________________
_____________________________________________________________________________________
Why do you feel that the City is responsible for this incident? ___________________________________
_____________________________________________________________________________________
I declare under penales for false swearing that to the best of my knowledge the informaon provided above
is true, correct, and complete.
________________________________________________________ _________________________
Signature Date
FOR CITY USE ONLY
Received By ___________________________________________ Date ___________________
1. Review form for completeness. Obtain missing informaon, if needed.
2. Inial and date above.
3. Make two copies; stamp “COPY” on them.
4. Provide one copy to claimant; Place other copy in appropriate department manager’s box.
5. Give original document to Shauna (Risk Management).
The City of Veneta is an equal opportunity employer and provider
88184 8th St PO Box 458 Veneta, Oregon 97487 Phone 541-935-2191 Fax 541-935-1838 www.VenetaOregon.gov
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