Fillable Instructions for Filling Out Citizen Claim Form 1) (City of LaGrange)

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Instructions for Filling Out Citizen Claim Form 1) (City of LaGrange)

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The Instructions for Filling Out Citizen Claim Form 1) (City of LaGrange) form is 4 pages long and contains:

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  • 2 check-boxes
  • 80 other fields

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Instructions for Filling Out
Citizen Claim Form
1) This is a claim form and not for filing a complaint against a City of LaGrange Department/Division.
2) There are three ways to submit this form:
a) Fill the form out online by clicking in the box and typing the requested information then hitting the submit button.
b) Print the form out and fill in all requested information and fax the form to:
(706) 883-2020
ATTN: Risk Management
c) Mail the completed form along with any additional attachments to:
Risk Management
City of LaGrange
200 Ridley Avenue
LaGrange, GA 30240
3) Please fill out only the information that relates to your claim.
4) If you have questions regarding this form or your claim, please contact the Risk Management Department at (706) 883-2016.
Location Code ________
CITY OF LAGRANGE
Citizen Claim Form
This form is designed to assist citizens in reporting an incident resulting in damage or injury that involved the City of
LaGrange.
1. GENERAL INFORMATION
Please fill out the General Information section for ALL claims.
Your name:
Your address:
City: State: Zip Code:
Home telephone number: (____) Cell number: (____)
Business telephone number: (____)
Date of incident: Time:
Address or location of incident:
2. INCIDENT INVOLVING A MOTOR VEHICLE
For any incident involving a motor vehicle you were operating or riding as a passenger, please complete the
following:
Private vehicle involved in incident:
Make of vehicle: Model: Year:
License number: State:
Driver: Age:
Owner of vehicle:
Insurance Company: Policy number:
Speed of vehicle at the time of the incident: Has the vehicle been repaired?
If the vehicle has been repaired, location of repair(s):
Cost of repair(s): Have the repair(s) been paid for? (If yes, attach receipt.)
If the repair(s) were paid for, who paid for them?
The damages consist of the following:
Has there been prior damage to this vehicle? Yes _____ No _____If yes, please explain:
3. INCIDENT INVOLVING A CITY OF LAGRANGE VEHICLE
If a City of LaGrange vehicle was involved in the incident, please complete the following:
City vehicle number: Department: Operator:
Make of vehicle: Model: Year:
License number: Speed of vehicle:
4. INCIDENT INVOLVING PROPERTY DAMAGE
For any incident involving property damage other than vehicle damage, please complete the following:
Property involved in incident:
Address:
City: State: Zip Code:
5. INJURIES
Please describe any physical injuries that occurred from the incident.
Name: Address:
Name: Address:
Nature of injuries:
Doctor(s):
Hospital(s):
Date of treatment:
Have you ever injured this body part? Yes ____ No ____ If yes, please explain:
Check here if no injuries:
6. WITNESSES
If there were any witnesses to the incident, please list their names, phone numbers and addresses below:
Name: Phone number: (____)
Address:
Name: Phone number: (____)
Address:
Name: Phone number: (____)
Address:
7. INVESTIGATION
Officer: Report/Case number:
8. CITY’S LIABILITY
Do you know if the City of LaGrange had direct knowledge about the problem and failed to correct it?
Explain in your own words how you were injured or how the damage occurred and in what way you believe the City of
LaGrange was responsible:
City Department involved in the incident:
City employee(s) involved in the incident:
Please attach any additional comments or pictures related to the incident to this form.
I affirm that the information submitted on this form is true and accurate to the best of my knowledge.
Signature: Date:
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Instructions for Filling Out Citizen Claim Form 1) (City of LaGrange)

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Completed 23 January 2021

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