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2. 
5. Claim No:
8. Date Rec'd:
12. First Name
13. Last Name
15. Name of Spouse if Applicable in Ownership of Damaged Property
17. Address
19. City
20. State
21. Zip Code
23. Phone Number
25. Information Concerning the Incident upon which claim is based:
27. Date and Time:
    Date and Time:

    Date and Time:
29. Weather Conditions:
30. Exact Location:
32. Name and Addresses of Witnesses: (If none, please state none)
34. Was the Incident Investigated by the Zanesville Police Department or other City Department?*

    1. Yes

    1. No
36. If Answer above was "yes", please indicate the Department that investigated and/or the name of any City Employee who may have investigated said occurrence:
38. In your own words, STATE IN DETAIL what happened and how it happened:
40. Property Damage Details:
42. Amount of Claim for Property Damage:
43. Do you have Homeowner's Insurance?

    1. Yes
    2. No
45. If Motor Vehicle Damage is Claimed:
47. Year:
48. Make:
49. Model:
51. Owners Name and Address:
53. Is Vehicle Covered by Collision Insurance?

    1. Yes
    2. No
54. If yes, Name of Company and Agent:
56. 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.
58. Where are you Employed:
59. How Long Employed?
61. If claim is for bodily injury, state the following:
63. Nature of Injury:
65. Were you Hositalized?

    1. Yes
    2. No
66. If yes, where?
67. For how long?
69. Were you Attended by a Physician?

    1. Yes
    2. No
70. If yes, who?
71. Physician's Address:
73. Amount Claimed for Bodily Injury Damages?
75. 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?

    1. Yes
    2. No
77. If yes, give details:
79. 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.
82. Signature of Claimant
84. Sworn to and subscribed before me this __________ Day of ________________ , 2020.
87. NOTARY PUBLIC
89. This document and any items submitted with itbecomes a public record per the Public Records Act under Revised Code 149.43.
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91. 1. Receive an email copy of this form.
92. Email address

    This field is not part of the form submission.

93. Submit Submit and Print

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