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Statement of Claim Against the City of Zanesville, Ohio

  1. Letterhead Template

  2. Claim No:

  3. Date Rec'd:

  4. Information Concerning the Incident upon which claim is based:

  5. Was the Incident Investigated by the Zanesville Police Department or other City Department?*

  6. Property Damage Details:

  7. Amount of Claim for Property Damage:

  8. Do you have Homeowner's Insurance?

  9. If Motor Vehicle Damage is Claimed:

  10. Is Vehicle Covered by Collision Insurance?

  11. Attach to email ESTIMATES OR RECEIPT(s) of Cost(s)in connection with the above claim (Vehicle or Property) ESTIMATES OR RECEIPT(s) MUST be FILED WITH CLAIM OR CLAIM CANNOT BE PROCESSED.

  12. If claim is for bodily injury, state the following:

  13. Were you Hositalized?

  14. Were you Attended by a Physician?

  15. Do you know whether or not the City had been notified of the conditions or circumstances concerning any street or sidewalk defect which may have been involved in the incident whic gave rise to your claim prior to the time of occurrence of said incident?

  16. The undersigned being first duly cautioned and sworn deposes and says that he or she has read the information contained in this foregoing statement or claim and that the same is true.

  17. Sworn to and subscribed before me this __________ Day of ________________ , 2020.

  18. This document and any items submitted with itbecomes a public record per the Public Records Act under Revised Code 149.43.

  19. Leave This Blank:

  20. This field is not part of the form submission.