Fillable NOTICE OF CLAIM INSTRUCTIONS: This form must be (City of Cottage Grove)

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NOTICE OF CLAIM INSTRUCTIONS: This form must be (City of Cottage Grove)

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NOTICE OF CLAIM
INSTRUCTIONS: This form must be completed immediately after an incident in which it is alleged that
the City may be responsible for reimbursement of damages.
No estimate or documentation need be attached if preparation of such delays filing the claim. The City
Clerk’s Office will forward the claim to its insurance agent.
RETURN COMPLETED FORM TO: City of Cottage Grove, ATTN: City Clerk, 12800 Ravine Parkway, Cottage
Grove, MN 55016.
Name of Claimant
Address of Claimant
Telephone Number of Claimant
Day Evening
Date of Occurrence Time of Occurrence
Location of Incident
Description of Claim
Extent of Damages
Why do you believe the City is responsible for damages?
_______________________________________ __________________________
Signature Date
SECTION RESERVED FOR INTERNAL USE
Date Received:
Date Forwarded to Insurance Agent: Forwarded by:
Comments:
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NOTICE OF CLAIM INSTRUCTIONS: This form must be (City of Cottage Grove)

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Completed 21 January 2021

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