Were there any witnesses?
** Medicare, Medicaid and SCHIP Extension Act of
2007 (
MMSEA Section 111)
Under MMSEA Section 111, any govermental entity that pays s
ettlement, judgment, award or other payment after July 1, 2009 is required to
report that claim to Medicare. To meet these mandatory reporting requirements, you will be required to submit your date of birth and social
security number before payment is made reguardless of the type claim you submit.
Against the City of Plano
Were you or anyone else injured? Yes No
FOR ALL CLAIMS – Have you submitted a claim to your insurance carrier? Yes No
THIS FORM MUST BE SIGNED AND DATED AS ACKNOWLEDGEMENT THAT ALL OF THE STATEMENTS MADE IN THIS
CLAIM ARE TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE:
Personal Injury – Property Damage
P.O. Box 860358
For status of your claim or to speak to an adjuster please call: 972-941-5654
YOU MAY SUBMIT THE COMPLETED CLAIM FORM ONE OF THREE WAYS:
Has the incident been reported to a City employee or department? Yes No
Date of Incident: _____________________________________________ Approximate Time: __________a.m. p.m.
Location of Incident:____________________________________________________________________________________
Please Print or Type Only
**SSN: _____________________________________
Date of Birth: _____________________________________
Date: _______________________________Signature:______________________________________________
If yes, please identify:___________________________________
E-Mail Address:____________________________________ Total amount of claim against the city: $______________________
Mailing Address:____________________________________City:_________________ State:_________ Zip Code:___________
Print Full Name: ____________________________________________Phone Number: _____________________________
Has the police department been notified? Yes No Police Report Number:______________________________
If yes, name of employee/department:_____________________________________________________________________
Describe in your own words where, when, and how the damage or injury occurred. Attach copies of
any bills, estimates, photographs, medical reports, or any other supporting documents
NOTICE OF CLAIM AGAINST THE CITY OF PLANO
Article 11 of the Charter of the City of Plano requires written notice within 6 months
of the incident before any claim for injury or damage may be considered.
The Charter provisions arequoted below for your information.
Section 11.06 – Special provisions Governing Damage Suits:
Before the city shall be liable to damage claim or suit for personal injury, or damage to property, the person who is injured or whose property is damaged or s
omeone in his behalf
shall give the city manager, or the person performing the duties of city secretary, notice in writing within six (6) months after the occurrence of the alleged injury, or damage, stating
specifically in such notice when, where and how the injury or damage was sustained, and setting forth the extent of the injury or damage as accurately as possible. No action at law
for damages shall be brought against the city for personal injury or damage to property prior to the expiration of thirty (30) days after the notice herein before described has been filed
with the city manager or the person performing the duties of city secretary, not later than two (2) years after the occurrence of the injury or damage to property. In case of injuries
resulting in death, before the city shall be liable in damages therefore the person or persons claiming such damages shall after the death of the injured person give notice as above
required in case of personal injury. Provided, however, that nothing herein contained shall be construed to mean that the City of Plano waives any rights, privileges, defenses or
immunities in tort actions which are provided under the common law, the constitution and general laws of the State of Texas.
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