Motor Vehicle Damage Claim Form - City Of Chicago Page 2
ADVERTISEMENT
1
212.
Incident Location:
(provide specific address,
i.e. 1234 W. Main St.):
13.
Witness Name (if applicable):
First
Middle Initial
Last Name
14.
Witness Address:
15.
Witness City, State & Zip Code:
16.
Witness Telephone:
Office
Home
Cellular
17.
Description of Incident (give
details of how damage
occurred)*
Use additional sheet if
necessary:
18.
Police Report Number:
19.
City Department Report
Number:
20.
Two Written Itemized Estimates
attached on company
letterhead or Itemized Paid Bill
with proof of payment
Two Written Estimates ______
Itemized Paid Bill ______
attached:
21.
Additional information
submitted
(i.e. photos, etc.):
22.
I am aware of the substantial
penalties, attorneys’, and legal
fees that may be imposed for
____________________________
____________________________
filing a false or fraudulent
Signature
Date
claim, pursuant to Municipal
Code Ch. 1, Sec. 1-22-020*:
23.
Certification - This signature
certifies that the information on
this form is true and accurate to
the best of my knowledge. I
have submitted this
information in a manner that
____________________________
____________________________
represents the true facts of this
Signature
Date
claim for the purpose of
investigating this claim*
Mail this form to:
REMEMBER
Office of the City Clerk/City of Chicago
121 North LaSalle Street, Room 107
--
Respond to all questions
Chicago, Illinois 60602
--
Attach supporting evidence and information
ATTN: CLAIMS
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal