Property Damage Claim Form - City Of Chicago
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1
2City of Chicago
Property Damage Claim Form
Please note:
Title 2, Chapter 2-12, Section 2-12-060 of the Chicago Municipal Code requires that all claims be printed legibly
and neatly.
PLEASE PRINT LEGIBLY AND NEATLY
* required information
Today’s Date:
1.
Claimant Name*:
First
Middle Initial
Last Name
2.
Claimant Address*:
3.
Claimant City, State & Zip Code:
4.
Claimant Telephone:
Office
Home
Cellular
5.
Claimant’s Email Address:
6.
Claimant’s Insurance Company:
7.
Policy Holder’s Name, Policy
Number and Policy Period:
Policy Holder’s Name: ____________________________________________
Policy Number: __________________________________________________
Policy Period: ____________________________________________________
(Effective Date)
(Expiration Date)
8.
Did you file a claim with your
insurance company?:
Yes _____
No _____
9.
Letter of Experience from
Insurance for all claims over
Yes _____
No _____
$500.00:
Must be provided for claims over $500.00
10.
Date and Time of Incident*:
Date ______/______/________
Time ______:______ A.M./P.M.
MM
DD
YYYY
11.
Incident Location:
(provide specific address,
i.e. 1234 W. Main St.):
12.
Witness Name (if applicable):
First
Middle Initial
Last Name
13.
Witness Address:
(OVER)
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Parent category: Business