Form Center

Your Information

Date & Time of Incident*
Date & Time of Incident
Date & Time of Incident
Location of Incident*
Description of alleged incident/accident and reasons the Town might be liable for your damages:*
Description of all damages you believe you have incurred as a result of the incident:*
Name(s) of any public employee(s) causing the injury, damage or loss you are claiming:
Dollar amount of all damages claimed:*
Type of Repair Bills & Medical Estimates
Check all that apply.
1. Repair Bills
2. Medical Bills
3. Auto Repair Estimates (minimum of 2 required)
Attachments
Please attach photos of the damages and any additional pertinent documentation below.
Should you need to include any items that exceed the maximum attachment size of 5MB, or you have additional documentation/photos beyond the available upload sections below, please email them to Risk Management.
For ease of tracking your claim, please include the subject line: Claim for Damages (Last Name, First Name) - Additional Documents
Attachment 1
Attachment 2
Attachment 3
Attachment 4
Attachment 5
Attachment 6
If this is a claim for indemnity, on what date were you served with the underlying lawsuit?
If this is a claim for indemnity, on what date were you served with the underlying lawsuit?
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By selecting the "I Accept" button and typing your name in the box below, you are signing this registration slip electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.
I certify (or declare) that the foregoing is true and correct to the best of my knowledge*
1. I Accept
Name*
Date*
Date
Please ensure all required fields have been completed, providing as much information as possible. You must click "Submit" to send your form to the Town staff. Upon clicking "Submit", a confirmation message of your submission will be displayed in your browser. If the confirmation message below is not displayed after clicking "Submit", your form will not be sent to Town staff.
Thank you for your submission. The claim will be processed as quickly as possible. An investigation, audit of receipts, and review by town management is required. The Town Manager or Council has final authority on the determination of all claims. It may take up to 45 days to determine if the claim will be accepted or denied. See Town of Truckee's Municipal Code for more information.

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