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Claim Form

Please correct the field(s) marked in red below:

1

 Name of Claimant(s)

 *
2

 Address of Claimant(s)

 *
3
Phone number of Claimant(s)
 *
4
Email address of Claimant(s)
 *
5

Nature of claim (property damage, bodily injury, and the like)

 *
6
Date, time and place of event on which claim is based
 *
7
Explanation of accident or event on which claim is based
 *
8
Amount claimed (please attach supporting documentation, if possible)
Amount claimed (please attach supporting documentation, if possible)
9
Reason for alleged Town responsibility (optional)
If claim involves property damage, please provide the following insurance information:
10
Name of Claimant's Insurance company
11
Address of Claimant's Insurance company
12
Claimant's Insurance policy number
  1. To receive a copy of your submission, please fill out your email address below and submit.