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Claim Form

If you've been involved in an accident and think you have a claim against the Metropolitan Government, please fill in the following information and someone in our Claims Division will contact you as soon as possible.

Claimant Information

Claimant's Name:
(Minors Only) Parents' Names:
Email Address:
Street Address:
Home Phone:
Work Phone:
Date of Birth:

Accident Information

Accident Date:
Accident Time: Accident Location:
Accident Description:

Injury Information

Injuries from or related to accident?:

Yes
No
Injured Name:
Injured Date of Birth:
Description of Injury:
Date of First Treatment:
Provider of Treatment:

Auto Claim Information

Year:
Make/Model:

Is Vehicle capable of being driven?:

Yes
No
If not, where is vehicle located?:
License tag#:
Description of Damage:

Witness Information

Witness 1:
Phone #:
Address:
Witness 2:
Phone#:
Address: