1

 Name of Claimant(s)

 *

Name of Claimant(s)

2

 Address of Claimant(s)

 *

Address of Claimant(s)

3

Phone number of Claimant(s)

 *

Phone number of Claimant(s)

4

Email address of Claimant(s)

 *

Email address of Claimant(s)

5

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

 *

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

6

Date, time and place of event on which claim is based

 *

Date, time and place of event on which claim is based

7

Explanation of accident or event on which claim is based

 *

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)

Amount claimed (please attach supporting documentation, if possible)

Amount claimed (please attach supporting documentation, if possible) Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

9

Reason for alleged Town responsibility (optional)

Reason for alleged Town responsibility (optional)

If claim involves property damage, please provide the following insurance information:

10

Name of Claimant's Insurance company

Name of Claimant's Insurance company

11

Address of Claimant's Insurance company

Address of Claimant's Insurance company

12

Claimant's Insurance policy number

Claimant's Insurance policy number

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

100%