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2. This is a filing of a claim against the City of Burlington, Iowa. You should complete this report in full and the written report constitutes your claim against the City of Burlington, Iowa. You are advised that no representations made by you to any employee of the City of Burlington, Iowa, is a part of this report unless in the report and that no representation made to you by any employee of the City of Burlington, Iowa, can in any way waive any of the requirements of law as to this report of your claim. You are further advised that failure to file this report within two (2) years of the date of the accident may invalidate your claim against the City of Burlington, Iowa.
4. To: City of Burlington, Iowa
6. You are hereby notified of the following claim made upon you by the undersigned as a result of the loss reported herein:
8. First Name
9. Last Name
11. Address1
13. City
14. State
15. Zip
17. Telephone/Cell Phone Number
19. Date of Loss
    Date of Loss
20. Time of Loss
    Time of Loss
22. Location of accident or loss. Be specific.
24. Describe accident or occurrence which caused injury or damage. Give full details upon which you have your claim. If an employee was involved, give his/her name.
26. What were weather conditions like?
28. Give name and address of any witnesses
30. Did police investigate the accident? If so, give name of police officers.
32. Was anyone injured? If so, give name, address and extent of injury.
34. Was any damage done to property? If so, describe property and extent of damage. Attach estimates of damages or describe basis for ascertaining extent of damage.
36. Please upload pictures and estimates
38. What other damages do you claim, if any?
40. Have you been compensated for any part, or all of your claim by any insurance company? If so, give name, address, and amount paid.
42. What amount do you claim in damages from municipality, city, town, county, governing body?
44. Have you made any claim against anyone else for damages as a result of this accident?
46. If so, give a name and address.
48. If you have filed a claim against someone else, have you received any payment from that source, and if so, in what amount?
50. Signature
52. Date
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit Submit and Print

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