Notice Of Claim Form printable pdf download

Notice Of Claim Form

City of Duncanville

NOTICE OF CLAIM FORM

203 E. Wheatland Rd.

Duncanville, TX 75116

972-780-5012

PERSONAL INJURY – PROPERTY DAMAGE

972-780-6495 (Fax)

CONTACT INFORMATION

Name

Home Address, City, State, Zip Code

Telephone Number

Business Address, City, State, Zip Code

Telephone Number

INCIDENT INFORMATION

Attach copies of invoices, estimates, photos, medical reports, etc. if possible. Please give details of your claim

against the City. Please include the nature, character of damage or injuries, the extent of any damages or

injuries, and any conditions that may have caused the damages or injuries. Use additional pages if necessary.

Location of Incident

Date of Incident

Medical Attention Required?

Police Report# if applicable

Description of Incident including property damage, if any:

All statements made in this claim are true and correct to the best of my knowledge.

Signature of Claimant

Date

By submitting this claim it does not guarantee liability nor the acceptance of liability by the City. All claims shall be

reviewed and processed by the City’s property and liability insurance provider.

The insurance provider is TMLIRP, PO Box 149194, Austin, TX 78714, 1-800-537-6655.

Notice Of Claim Form