Claims Against the City of Chandler
For Damages to Persons or Personal Property
All sections of the form should be completed in its entirety. When necessary, please use additional paper for each line.
1. Name of Claimant______________________________________ Spouse Name____________________________________________
Date of Birth___________________
2. If a Minor, Name________________________________________ Name of Guardian_______________________________________
Date of Birth___________________
3. Address of Claimant______________________________________________________________________________________________
Home Phone No. _______________________________________ Work Phone No. ________________________________________
Email: ____________________________________________________
4. Occurrence or event from which the claim arises:
a. Date of Loss _________________________ b. Time of Loss _____________________________
c. Location of Incident (exact and specific) ________________________________________________________________________
____________________________________________________________________________________________________________________
d. Specify the particular occurrence, event, act or omission you claim caused the injury or damage.
_________
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
e. State in what manner you believe the City of Chandler or its employees were at fault.
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
5. Give the name(s) of any City employees having knowledge of or involved in the incident, (if auto accident involving
a City vehicle, please provide City vehicle description & license plate number, driver name, department).
_________
__________________________________________________________________________________________________________
_______
____________________________________________________________________________________________________________
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Law/Risk Management
6. Describe the injury, property damage, auto damage or loss (include name and address of other person(s) injured).
a.
I
f there were no injuries, state “no injuries
.
____
______________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
b
. If claiming injury, are you a Medicaid/Medicare recipient? Yes________ No________
c. Auto damage, please draw a diagram illustrating location and how loss occurred.
Provide your vehicle information. Year________ Make____________ Model_______________ License Plate
_____________
**ALL PROPERTY DAMAGE CLAIMS MUST BE ACCOMPANIED BY A PHOTOGRAPH AND TWO ESTIMATES**
7. Please state a specific amount for which you will settle your claim. $ _______________________________
Basis for computation of amounts claimed (include copies of all bills, invoices, estimates, receipts, etc.)
___________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
8. Name, address, phone numbers of all witnesses, hospitals, doctors, etc.
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
9. Please provide police report or fire report number if applicable. _________________________________________________
10. Any additional information that might be helpful in considering claim.
___________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
___
WARNING! IT IS A CRIMINA
L OFFENSE TO FILE A FALSE CLAIM.
(Sec A.R.S. 13-2310 Insurance Code 44-1220)
ALL CLAIMS MUST COMPLY WITH A.R.S § 12-821.01 ET SEQ., AND MUST BE FILED WITHIN 180 DAYS AFTER THE CAUSE OF ACTION
ACCRUES. BY PROVIDING THIS CLAIM FORM, OR ENTERING INTO ANY DISCUSSIONS OR NEGOTIATIONS WITH YOU, THE CITY OF
CHANDLER DOES NOT WAIVE ANY OF DEFENSES WHICH MAY BE AVAILABLE PURSUANT TO APPLICABLE LAW. IF YOU ARE UNSURE
OF YOUR LEGAL OBLIGATIONS, PLEASE CONSULT A LAWYER. THIS FORM IS OFFERED BY THE CITY FOR CONVENIENCE PURPOSES
ONLY – THE CLAIMANT(S) REMAIN(S) SOLELY RESPONSIBLE TO INSURE COMPLIANCE WITH STATE LAW.
I have read the matters and statements made in the above claim. I know the same to be true of my own knowledge,
except as to those matters stated upon information or belief and as to such matters, I believe the same to be true. I
certify under penalty of perjury that the foregoing is true and correct.
Signed this _______________ day of ______________________________, 20________ at ________________________________________
C
laimants Signature __________________________________________________________________________________________________
NOTE: Claims must be filed within 180 days after the cause of action accrues.
2 of 2 Revised 12/03/19
Law/Risk Management
