Name (Property Owner or Injured Person)*

Email Address*

Street Address*

City*

State*

Zip Code*

Home Phone*

Cell Phone*

Work Phone

Date of Incident:*

Location of Event (Where Incident Occurred)*

Property Damaged and/or Injury Sustained*

Estimate Amount of Damage/Injury*

Describe incident in detail. Include verbatim statements of person(s) suffering injury or property damage, and witnesses. Ask key witnesses to write statements. State how you believe the City caused or contributed to the damage/injury. State nature and extent of injuries.*

Witness #1 Name

Witness #1 Address

Witness #1 Phone

Witness #2 Name

Witness #2 Address

Witness #2 Phone

Documentation

Estimates Pictures Records

Statements Other

Documentation Upload #1

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Documentation Upload #2

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Documentation Upload #3

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Documentation Upload #4

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Name of any city employee with knowledge of incident

If you need to send paperwork via mail, send to:
Office of City Attorney
PO Box 5503
Bismarck ND 58506-5503

By submitting this claim form, I understand that I am asking the City of Bismarck to consider my claim for reimbursement.

The City will be reviewing the incident to determine whether it will offer payment to you for the loss.

Date*