Claim Form

NOTICE REQUIRED: Any person claiming to have suffered an injury or property damage by a public entity or by an employee thereof, while the course of their employment, shall file a written notice as provided by the COLORADO REVISED STATUTES, Section 24-10-109, within one hundred eighty two (182) days after the date of the discovery of the injury or damage.

Claimant Details

First Name

Last Name/Company Name

Date of Birth

Address	City
State	Zip
Phone Number Please enter your 10 digit phone number	Email Address

Is there another party representing you for this claim?

Other Party Details

First Name	Last Name/Company Name
Address	City
State	Zip
Phone Number Please enter your 10 digit phone number	Email Address
Relationship to Claimant

Incident/Claim Details

Date	Time Format Example 6:45 am or 12:36pm
Address	City
State	Zip

Please describe the incident

Please describe how the City was negligent

Were bodily injuries sustained?

Was a personal/business vehicle involved?

Was there property damage?

Was a City vehicle involved?

Was a City employee involved? (e.g. City vehicle driver)

Do you know the name of the City employee?

Police Report # (If applicable)

Bodily Injury Details

Nature of the Bodily Injury

Estimated Damage ($)

Please insert dollar amount only. Leave blank if unknown.

Personal/Business Vehicle and Driver Details

Year	Make If make not known, please insert "N/A"
Model	License Plate Number
Insurance Company	Insurance Phone

Description of Damages

Estimated Damage ($)

Please insert dollar amount only. Leave blank if unknown.

Is the driver the Claimant entered above?

Is the driver's information available?

Driver's First Name	Driver's Last Name Enter "Unknown" if not known
Driver's Phone (Home)	Driver's Phone (Work)
Driver's License #

Property Details

Description of Damages

Estimated Damage ($)

Please insert dollar amount only. Leave blank if unknown.

City Employee Details

First Name	Last Name
Department

Attachments

Do you wish to add Files/Attachments?

Note: There is a 25 MB per file size limit, a 35 MB total file size limit, and a 10 file limit per submission.

Please upload any supporting documents, images, invoices, or estimate of damages.

File Upload

To add more than one attachment, select "Add another file". To remove the additional file upload option, select "Remove".

Declaration

I understand that submitting this claim form does not signify an admission of liability by the City of Fort Collins or Poudre Fire Authority. By checking this box, I am electronically signing this claim form.

I agree