Motor Vehicle Damage Claim Form - City Of Chicago
ADVERTISEMENT
1
2City of Chicago
Motor Vehicle 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.
Driver’s License Information. If
you do not have a license
Driver’s License No. _____________________________________________
please include your State ID
(include a copy of your license
with your claim submission):
State of Issuance ________________________________________________
7.
Claimant’s Insurance Company
(include a copy of your
insurance card):
8.
Policy Holder’s Name, Policy
Number and Policy Period
Policy Holder’s Name: ____________________________________________
(include a copy of your
insurance card):
Policy Number: __________________________________________________
Policy Period: ____________________________________________________
(Effective Date)
(Expiration Date)
9.
Did you file a claim with your
insurance company?:
Yes _____ (Claim Number __________________)
No _____
10.
Letter of Experience from
Insurance Company (must be
Yes _____
No _____
provided for all claims over
$500.00):
11.
Date and Time of Incident*:
Date ______/______/________
Time ______:______ A.M./P.M.
MM
DD
YYYY
(OVER)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal