Claim Form

1 NOTICE OF CLAIM AGAINST THE CITY OF TEMPLE Complete and Return to: Trasdy Newman, Legal Specialist/Paralegal City Attorney’s Office 2 North Main Street, Suite 308 Municipal Building Temple, TX 76501 P: 254-298-5674 F: 254-298-5711 tnewman@templetx.gov Please Print and Complete Both Pages of this Form FULL NAME: PHONE NUMBERS: Home:_________________________ MAIL ING ADDRESS: Business:_______________________ CIT Y, STATE AND ZIP CODE: Cell:___________________________ LOC ATION OF INCIDENT: APPROXIMATE TIME AM OF INCIDENT: PM DATE OF INCIDENT: DESC RIBE IN YOUR OWN WORDS WHERE, WHEN AND HOW THE DAMAGE OR INJURY OCCURRED. ATTACH ADDITIONAL PAGES IF NECESSARY. HOW INCIDENT HAPPENED: Receipt of this claim form does not imply that the City is responsible for any damages/losses you have allegedly sustained. Once received, the claim will be forwarded to our risk pool partner, Texas Municipal League, for review and/or investigation. 2 WHO IS YOUR INSURANCE CARRIER? FOR VEHICLE ACCIDENTS: WHAT IS THE YEAR, MAKE, MODEL, AND LIENHOLDER FOR DAMAGED VEHICLES? LIST THE NAMES, ADDRESSES, AND PHONE NUMBERS OF ALL WITNESSES YOU ARE RELYING ON TO ESTABLISH YOUR CLAIM. Signed this the day of , 202__. Claimant's Signature