****Please keep a copy of this claim for your records. No photocopies will be provided.****
FILE THIS FORM AND ANY ATTACHMENTS WITH
OFFICE OF THE MAYOR, CITY HALL – 166 BOULDER DRIVE, FITCHBURG, MA 01420
Claimant: ___________________________________________Home Phone:_ ________________________
Address: ____________________________________________Business Phone:_______________________
Date and Time of Incident: _____________________________Cell Phone:___________________________
Location of Incident (Street name, number, and/or nearest intersection):_____________________________
__________________________________________________________________________________________
Type of Accident: ( ) Injured Person ( ) Property Damage ( ) Automobile Accident
1. Name & Address of Person to whom notices should be sent to (if other than claimant):
____________________________________________________________________________________
2. Description of the incident, including your reason for believing that the City is liable for your damages:
(Please attach additional pages if necessary)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Name and address of any witnesses: ____________________________________________________
3. What sum do you claim? (A professional estimate of cost for repairs or replacement to be attached to
this form)
Description of Estimate or Bill
(Attach additional pages if necessary)
Total: $ _________
4. Will you provide photos to support your Claim? ( ) Yes ( ) No
- Photos provided will not be returned, please make a copy for your own records or
- e-mail photos (no more than five) to vpusateri@pusaterilaw.com include your name and date of
loss
5. Police report filed? ( ) Yes or ( ) No 6. If yes, is the report included in this claim? ( ) Yes ( ) No
Signature of Claimant: Date:
Claims Form
Office of the Mayor
166 Boulder Drive
Fitchburg, MA 01420
978-829-1801
click to sign
signature
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