Claim Request Form

1. Claimant Information

Claimant Name *

Phone *

Email *

Address *

Address

City

State

Zip

Date of Birth *

2. Occurrence or Events Giving Rise to the Claim

Date of Occurrence *

Location *

Provide the specifics of the occurrence, event. Act or omission that you claim caused your injury or damage: *

Describe how or why you believe the City or employee was at fault: *

If this was a vehicle accident, state what road or highway the accident occurred on: *

Your vehicle license plate number: *

VIN: *

Year: *

Make: *

Model *

License plate of the City vehicle involved:

Name of City driver:

Was a police report filed? *

Yes

I don’t know

Name of police agency involved: *

Description of Property Damage and Injuries

Describe the property that was damaged: *

Dollar amount for which you would settle your property damage claim *

Describe the personal injuries suffered: *

Dollar amount for which you would settle your personal injury claim *

Witnesses

List all witnesses, with their name(s), address and phone #: *

Are there any additional comments, details or information you want us to consider in responding to your claim?

By signing you verify the information presented in this claim is to the best of your knowledge and belief.

Sign or Type your Name *

Clear

Date *

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Clerk Staff

City Clerk
Leticia Robinson
520-287-6571
[email protected]

English/Español »

Claim Request Form

1. Claimant Information

2. Occurrence or Events Giving Rise to the Claim

Description of Property Damage and Injuries

Witnesses

Clerk Staff

City of Nogales

Resources

Economic Development

Contact Us

Contact Us

520-287-6571

Address

777 N. Grand Ave
Nogales, AZ, 85621

Contact Form

Claim Request Form

1. Claimant Information

2. Occurrence or Events Giving Rise to the Claim

Description of Property Damage and Injuries

Witnesses

Clerk Staff

City of Nogales

Resources

Economic Development

Contact Us

Contact Us

520-287-6571

Address

777 N. Grand Ave Nogales, AZ, 85621

Contact Form

777 N. Grand Ave
Nogales, AZ, 85621