City of Worcester Claim Application

Claimant's Email address

Home Phone

Work Phone

Nature of claim: (e.g., auto accident, slip and fall on public way or property damage):

Date and time of incident

Exact location of incident: (include as much detail as possible):

Vehicle:

Year

Make

Model

Vehicle Mileage:

Circumstances of the incident:

Have you submitted a claim to any insurance company for damages arising from this incident?

Yes

If yes, please provide the name, address, phone number and contact person of insurance company. Also provide the claim number

Optional Upload File(s)

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Amount of damages claimed:

Be sure to attach any bills incurred or any written estimates of repair or replacement costs. (Any documents that you provide will become the property of the City of Worcester. Therefore, it is suggested you keep copies of any such documents for your files.) Attach any other information you believe will be helpful in the processing of your claim (for example, names and addresses of any witnesses, written medical records if personal injury was sustained).

I certify under the pains and penalties of perjury that the foregoing information is true and correct

Electronic Signature Agreement

I Certify that I agree to use an electronic signagure.

Claimant's Signature:

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Date Submitted:

WHEN TO FILE: If your claim is based on a defect in a public way, you must file within 30 days of the incident. If your claim is based on the negligence or wrongful act or omission of the City or its employees, you must file within two years of the incident.

Submit this form electronically upon completion or print it out and return to: City Clerk, City Hall Room 206, 455 Main Street, Worcester, MA 01608.

For further advice as to the procedure for filing your claim, you should consult a private attorney. NOTE: In the event your claim is denied by the City of Worcester, you have the right to request a hearing before the Claims Committee. You must request this hearing in writing to the Law Department, City Hall Room 301, 455 Main Street, Worcester, MA 01608, and you must be prepared to appear in person on the date that the hearing is scheduled.