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City of Worcester

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455 Main Street, Worcester, MA, 01608, US

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City of Worcester Claim Application

Claimant's name:

Claimant’s complete address:

Date and time of incident

Date Picker

Vehicle:

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

Optional Upload File(s)

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

Claimant's Signature:

Choose how to sign

Date Submitted:

Date Picker

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.