Claim Submission Form
Claim Submission Form
Please fill out this form completely and accurately. Provide as much detail as possible to help us understand the incident. If you have any questions, please contact
City of Westminster Risk Management
at
claims@westminsterco.gov
.
Reporter Details
First Name
Enter your first name only.
Last Name
Enter your last name (surname or family name).
Email
Example: yourname@example.com
Phone
Expected Format: 555-555-1234
Street Address
Enter house number and street name. Example: 123 Water Street
City
City may auto-fill. Please verify.
State/Province
State/Province may auto-fill. Please verify.
Calculated State/Prov
Country
The country may auto-fill. Please verify.
Zip/Postal Code
Verify code (e.g., A1A 1A1 or 12345)
Are you the person affected by this incident?
Please select...
Yes
No
Affected Person: An individual reporting harm or property damage related to a specific event, action, or omission.
AFFECTED PERSON DETAILS
First Name
Enter first name only.
Last Name
Enter last name (surname or family name).
Email
Example: person@example.com
Phone
Expected Format: 555-555-1234
Street Address
If known enter house number and street name. Example: 123 Water Street
City
City may auto-fill. Please verify
State/Province
State/Province may auto-fill. Please verify.
Calculated State/Prov
Country
Country may auto-fill. Please verify.
Zip/Postal Code
Verify code (e.g., A1A 1A1 or 12345)
ADDITIONAL INVOLVED PEOPLE
Would you like to add additional involved people?
Please select...
Yes
No
Select 'Yes' to enter details for one or more people involved (e.g. witness or lawyer).
ADDITIONAL INVOLVED PERSON DETAILS
First Name
Enter first name only.
Last Name
Enter last name (surname or family name).
Email
Example: person@example.com
Phone
Expected Format: 709-555-1234
Street Address
Enter house number and street name. Example: 123 Water Street
City
City may auto-fill. Please verify.
State/Province
State/Province may auto-fill. Please verify.
Calculated State/Prov
Country
Country may auto-fill. Please verify.
Zip/Postal Code
Verify code (e.g., A1A 1A1 or 12345)
What Happened?
Describe what happened
Provide a factual account: What happened, where, when, who was involved, and actions taken.
Was a Police Report Filed for this Incident?
Yes
No
Select 'Yes' if an official report was made to the police.
Police Report File Number
This is the police report file number you would have received when reporting the incident to the authorities. If you do not have one it is okay to leave this field blank.
Additional information
Does this incident involve a vehicle?
Does this incident involve property damage?
Does this incident involve bodily injuries?
Select all that apply. Checking an option will reveal a section for more details.
Where did incident take place?
Street Address Lookup
Search for and select the incident location address. Verify auto-filled details below.
City
City may auto-fill. Please verify.
State/Province
State/Province may auto-fill. Please verify.
Calculated State/Prov
Country
Country may auto-fill. Please verify.
Zip/Postal Code
Verify code (e.g., A1A 1A1 or 12345)
When did the incident take place?
Date of Incident
Format: MM/DD/YYYY. Cannot be a future date.
Time of Incident
HH
Please select...
01
02
03
04
05
06
07
08
09
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12
MM
Please select...
00
01
02
03
04
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59
AM/PM
Please select...
AM
PM
INJURY DETAILS
Injury Description
Factually describe the injury (type, body part, apparent severity). Avoid diagnosis.
Involved Vehicle/Equipment
Note: If you do not know the specific details of the vehicle, please use "N/A"
Vehicle
/
Equipment
Make
Enter the make (e.g., Ford, Caterpillar).
Vehicle
/
Equipment
Model
Enter the model (e.g., F-150, 320).
Vehicle
/
Equipment
License Plate Number
Enter license plate number (e.g., AAA-123), if applicable.
Vehicle
/
Equipment
Year
Enter 4-digit year (e.g., 2023).
Vehicle
/
Equipment
Type
Please select...
Ambulance
ATV
Bus
Convertible
Coupe
Crossover
Fire Truck
Garbage truck
Hatchback
Motorcycle
Passenger
Patrol
Pickup Truck
Sedan
Snowmobile
Snowplow
Station Wagon
SUV
Taxi/Limousine
Tractor
Transport Truck
Van
Van Conversion
Zamboni
Watercraft
Select type (e.g., Pickup Truck, Bus).
Vehicle Name
Description of Damages
Describe the damage (e.g., Dented fender, flat tire).
To add another vehicle, please select "Add Another Vehicle" on the bottom-right portion of this section.
Property Damage
Street Address
Enter street number and name. Example: 123 Water Street
ASSET NAME
City
City may auto-fill. Please verify.
State/Province
State/Province may auto-fill. Please verify.
Country
The country may auto-fill. Please verify.
Calculated State/Prov
Zip/Postal Code
Verify code (e.g., A1A 1A1 or 12345)
Description of Damages
Describe the damage (e.g., Broken window at main entrance, Damaged landscape).
To add another property, please select "Add Another Property" on the bottom-right portion of this section.
Attachments
Do you wish to add Files/Images?
Please select...
Yes
No
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 Response". To remove the additional file upload option, select "Remove".
Contact Information