Citizen Request to File a Claim

This form is to be completed by the Citizen filing a claim for damages or reimbursement from the Town of Mooresville. Please complete all applicable information and be as specific as possible. Attach any documentation available (i.e. Police Report, invoices, bills, estimates, photographs, etc.). If estimates are attached, two (2) independent estimates for repair / maintenance must be provided. This information will be provided to the Town’s insurance adjusting firm for investigation and disposition of the Claim.

BY SUBMITTING THIS FORM, THE TOWN OF MOORESVILLE IN NEITHER ACCEPTING NOR DENYING LIABILITY OR RESPONSIBILITY FOR THE OCCURRENCE DESCRIBED BELOW. AN INVESTIGATION WILL BE CONDUCTED BY THE TOWN OF MOORESVILLE. FURTHER INFORMATION MAY BE REQUIRED FROM THE CLAIMANT. THE CLAIMANT WILL BE NOTIFIED BY MAIL AS TO THE FINAL DISPOSITION OF THE CLAIM BY THE TOWN'S INSURANCE ADJUSTING FIRM.

Date of Occurrence

Time of Occurrence

Location of Occurrence

Claimant Address

Home Phone Number

Work Phone Number

Occurrence Information

Extent of Damages

Estimate of Damages ($)

Attach Documentation

Insurance Information

Insurance Company

Policy Number

Agent

Agent Phone Number

Witness Information

Witness Name

Witness Address

Agreement

THE ABOVE IS A TRUE, COMPLETE AND ACCURATE STATEMENT OF THE FACTS OF MY CLAIM. I AUTHORIZE THE TOWN OF MOORESVILLE TO INVESTIGATE MY CLAIM AND TO OBTAIN INFORMATION, INCLUDING CONFIDENTIAL OR MEDICAL INFORMATION THAT MAY BE RELEVANT TO MY CLAIM.

I agree

I do not agree