Fillable Notice-of-claim (Insert logo)

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Notice-of-claim (Insert logo)

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The Notice-of-claim (Insert logo) form is 3 pages long and contains:

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  • 8 check-boxes
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File type: PDF

U.S.A. forms for City of Fortworth

BROWSE CITY OF FORTWORTH (TX) FORMS

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Page 1 of 3
HUMAN RESOURCES
RISK MANAGEMENT DIVISION
City of Fort Worth 1000 Throckmorton Street Fort Worth, TX 76102
Office (817) 392-7402 Fax (817) 392-5874
Procedures for Filing Your Claim
Notice: Prerequisite to Lawsuit for Damages
Charter XXVII, Section 25, Charter of the City of Fort Worth
States in part, ……. “Written notice shall be filed within or before the expiration of one hundred eighty
days”. If such notice is not filed within 180 days, the circumstances establishing good cause for such failure
is required.
About The Claim Form
The claim form is provided to assist you in filing your claim. Unless married, each claimant must submit their own
separate claim. If more space is needed, attach separate sheet to claim, along with any documentation needed
to substantiate your claim. In order for your claim to be considered, this form must be completed, signed and filed
with the City’s Risk Management office.
By accepting the completed form, the City is not admitting liability or acknowledging the validity of a claim.
How To File A Claim – the claim form may be submitted by any one of the following:
By Mail Email
City of Fort Worth RskMgt@fortworthtexas.gov
Attn: Risk Management
1000 Throckmorton Street
Fort Worth, Texas 76102
By Fax
817-392-5874
What Happens After A Claim Is Filed?
Once a claim is received, an in-house adjuster is assigned to conduct an investigation. However, a third party
contractor for the City may perform the investigation or assess damages. Until a final decision is made on a claim,
any statement or offer made concerning your claim by any City employee or its agent is unauthorized and not
binding on the City. Final approval or denial will be conveyed to you by the adjuster assigned to you claim.
Also, by filing a claim, you agree to allow the city or its agent to inspect your property or to investigate the personal
injury. Unreasonable refusal of such inspection or investigation may be grounds for denial of your claim.
If the City’s investigation determines a different party may be responsible, the City will notify the claimant so the
claimant may take appropriate steps.
Page 2 of 3
CITY OF FORT WORTH
CLAIM FOR DAMAGES
CLAIMANT INFORMATION
Name:
Current Address:
City State Zip
Phone (Day) (Cell)
Email
CLAIM INFORMATION
Date Claim Occurred
Time
AM / PM Location
Describe How Claim Occurred
PROPERTY DAMAGE Submit two (2) estimates of damage
Or a copy of any receipts to substantiate
Amount Claimed: $ your claim. *Not Mandatory
Description of Property - (if auto, include year, make, model & license #)
If auto accident: list name of driver if not same as claimant:
Page 3 of 3
PERSONAL INJURY
Amount Claimed: $
Describe Injuries:
Were you treated at a hospital? Yes / No Name of Hospital
Are you currently being treated by a physician? Yes / No
If yes, list physician’s name and phone number
ADDITIONAL CLAIM INFORMATION
Were police called to the scene? Yes / No Police Report Number (if
available) Passenger &/or Witness information (if any)
Name Address Phone Number
FOR ALL CLAIMS – Have you submitted a claim to your insurance carrier? Yes / No
Complete the following if your answer above is yes:
Date Filed
Insurance Company
Policy # Claim #
Adjuster’s Name/Phone
PLEASE BE ADVISED: Any person who knowingly presents a false or fraudulent claim for payment
of a loss is guilty of a crime and may be subject to fines and confinement in prison as per Texas
Penal Code §35.02.
CLAIMANT SIGNATURE: Claim form must be signed and dated by an adult claimant (18 years or older -
or by both adults if the claim is jointly filed by a married couple; by the parent on behalf of a child suffering
injury or loss; by a person holding a written power of attorney from the claimant; or by a court-appointed
guardian.
X Date
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Completed 12 July 2020

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