1

Please provide your contact information.

Please provide your contact information.

Name

Phone Numberext.

Address

E-mail Address

2

What type of damage ocurred?

What type of damage ocurred?

Property - Real Estate - Personal Possessions

Vehicle

Personal - Bodily

Other

3

When did the damage occur? (Best guess if unknown)

When did the damage occur? (Best guess if unknown)

When did the damage occur? (Best guess if unknown)

Time

4

Where did the damage occur geographically?  Please describe the area or an address, if available.

Where did the damage occur geographically? Please describe the area or an address, if available.

5

What was the cause of the damage?

What was the cause of the damage?

6

If vehicular, please provide:

If vehicular, please provide:

Year	Make
Model	Color
License Plate (example: IA, 123 456)	VIN (if known)

7

Please provide a brief narrative of what occurred.  Please use as many facts and verifiable information as possible.  If you have already discussed the matter with a City Employee, please give their full name and title if possible.

Please provide a brief narrative of what occurred. Please use as many facts and verifiable information as possible. If you have already discussed the matter with a City Employee, please give their full name and title if possible.

8

Attach any photos available.

Attach any photos available. Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

Page 1 / 1