Fillable NOTICE OF CLAIM FORM (Matters Less Than $10,000.00) (City of Bisbee)

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NOTICE OF CLAIM FORM (Matters Less Than $10,000.00) (City of Bisbee)

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NOTICE OF CLAIM FORM
(Matters Less Than $10,000.00)
PLEASE READ THE FOLLOWING INSTRUCTIONS BEFORE COMPLETING THE NOTICE OF CLAIM FORM.
(1)
The Notice of Claim form must be completed in its entirety and returned to the City of Bisbee,
A
rizona.
T
he Notice of Claim Form must be served within 180 days of the Injury or Property Damage to:
City Clerk, City of Bisbee
76 Erie Street #4601
Bisbee, AZ 85603
(2)
Persons, bringing claims against the City of Bisbee or one of its employees, must file a claim within 180 days
after the cause of action accrues. The City does not waive any requirement of formal service for the claim, and
Arizona law requires that the claim contain sufficient facts for the City to understand the basis upon which
liability is alleged. The claim must also include a specific amount for which the case could be settled, and the
specific facts which support that amount.
(3)
The City of Bisbee recommends consulting with an attorney of your choosing for the purpose of handling any
significant claim.
(4)
The receipt of the Notice of Claim Form against the City is not an admission by the City of liability for the alleged
damage or injury, nor is it a promise to pay for the injury or property damage. Once the claim form is received,
it will be forwarded to the City’s Claims Adjuster, Southwest Risk, for review. A representative of Southwest Risk
will contact you at the address and phone number listed on the Notice of Claim form. Effort will be made to
make decisions about your claim as quickly as possible.
(5)
The receipt of proper documentation to substantiate your claim will allow the fastest handling of your claim.
Types of documentation includes, but is not limited to:
(
a) Medical reports/medical statements;
(b) Fully itemized estimate of damages; and or repairs
(c) A complete description of damaged property including brand name, model/make, year serial
n
umber, date of purchase, purchase cost, etc.;
(d) Photographs (if available);
(e) Witness statements; and
(f) Police reports (if applicable).
P
roviding information listed above does not guarantee the payment of your claim. The City’s insurance carrier
reviews all claims. City staff does not determine claim eligibility.
(6)
Your claim is not considered submitted, nor proper notice received, unless the Notice of Claim Form is
properly completed and signed. Speaking to any City employee or a letter without all of the requested
information does not service as proper notice.
Full Name:
Mailing Address:
Home Address:
City: State: Zip Code:
Home Number: Work Number:
Cell Phone Number: Other:
Date/Time of Incident:
Auto Insurance Co.: Phone:
Home Owner Insurance Co.: Phone:
Location of Incident (be specific):
The Total amount of your claim against the City is $
P
rovide the details of your claim against the City. Describe in your own words, where, when, and how the damage
or injury occurred. Attach additional sheets if necessary. Give names, addresses, and phone numbers of others
involved or witnesses of the incident, if known. Provide a detailed statement of each item of damages. Attach
copies of any bills, estimates, photographs, medical reports, etc., if applicable.
A
LL OF THE STATEMENTS MADE IN THIS CLAIM ARE TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE:
D
ate Signature of Claimant
RECEIVED STAMP INCLUDE TIME
SIGNATURE OF CITY CLERK OR DEPUTY CITY CLERK
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NOTICE OF CLAIM FORM (Matters Less Than $10,000.00) (City of Bisbee)

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Completed 1 February 2021

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