Manager
Resume:
Finance Department
Risk Management Division
The City of Phoenix Risk Management claim form is attached. If you wish to present a claim to the City, please complete the form and file it as noted on the form. It is important that you provide all information requested on the claim form so that we may make a prompt, comprehensive and fair evaluation of your claim. Failure to do so will result in the rejection of your claim. In addition to the information required on the claim form, you can facilitate the processing of your claim by including copies of medical bills and repair estimates of property damage. Please note that each person filing a claim against the City must fill out a separate claim form. You may make a copy of the attached blank form for each person to complete. Once we receive your completed claim form, we will investigate your claim to determine whether and to what extent, if any, the City may be liable. The City can pay only those claims for which the City is legally liable.
Please be aware that you are legally responsible to minimize any loss, to protect property from further damage and to preserve potentially relevant evidence. If you have questions, please contact our office for assistance at 602-***-****. Sincerely,
RISK MANAGEMENT DIVISION
Enclosure
AVAILABLE IN ALTERNATIVE FORMATS BY CALLING THE RISK MANAGEMENT DIVISION
602-***-**** - TTY CITY RELAY OPERATOR 602-***-**** - FAX 602-***-**** 251 W. Washington St., 8th Fl., Phoenix, AZ 85003
Rev 6/7/21
Claim Form
This claim form is provided to assist in presenting a claim against the City of Phoenix that complies with the requirements of Arizona Revised Statutes §12-821.01 which defines the requirements for filing a claim against a public entity in the State of Arizona.
The Statute requires, in part, that a claim against a public entity:
Be filed with the City Clerk Department within 180 days after the cause of action accrues,
Contain sufficient facts to permit the public entity to understand the basis upon which liability is claimed,
Contain a specific dollar amount for which the claim can be settled and the facts supporting the amount.
In order to file suit against a public entity, a proper notice of claim must first be filed. A lawsuit must be filed within one year after the cause of action accrues. FEDERAL REGULATION – BODILY INJURY CLAIMS ONLY
If you are presenting a bodily injury claim, you are required to provide the information requested in this section pursuant to Federal Law – Section 42, United States Code 1395y(b) (7) & (8). For additional information, go to https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group- Health-Plans/Overview
Injured party name:
(Show name exactly as it appears on Social Security records) Injured party social security #:
Injured party gender: Male Female Injured party date of birth: Medicare, Medicaid (AHCCCS) or SCHIP Health Ins Claim #:
(HICN if applicable)
Is the injured party eligible (or will he/she be eligible within the next 36 months) for Medicare, Medicaid
(AHCCCS) or the State Children’s Health Insurance Program (SCHIP)? Yes No Please continue to the claim form below. Additional information is required. 1. CLAIMANT INFORMATION (complete a separate claim form for each person making a claim) Claimant Name:
Name of claimant’s representative (if
applicable):
Relationship to
claimant:
Parent (claimant is a minor) Guardian Insurance Company Attorney Other Address: Apt #:
City / State: ZIP:
Date of birth:
Phone
#s
Home: Work: Cell: Page 1 of 4
This claim form is available in alternative
formats upon request.
TTY 602-***-****
If more space is needed, please attach
additional pages.
If you have any questions, please call the
Risk Management Division at: 602-***-****
Rev 6/7/21
Which is the best daytime phone # to reach you?
Email address: Fax #: 2. OCCURRENCE OR EVENTS GIVING RISE TO THE CLAIM
Date of occurrence: Time: A.M. P.M.
Location of occurrence:
Describe the specific facts of the occurrence, event, act or omissions that you believe caused your injury or damage and for each theory of liability, explain why you believe the City of Phoenix is at fault. List all witnesses, including name(s), address and phone number. Did this occur in a construction area? Yes No
If yes, what is the construction company’s
name?
If this is a motor vehicle accident, please provide the following information: Your vehicle license plate number:
Your vehicle: Year: Make: Model:
Name of the City driver:
City Vehicle Description: City Department:
City Vehicle License Plate
#:
Bus/Equipment #:
Bus Route Name/Number: Direction of Travel
Was a police report filed? Yes No If yes, what agency responded?
Police report number:
Page 2 of 4
Rev 6/7/21
3. AMOUNT OF CLAIM
Dollar amount requested to settle your entire property damage claim: $ Dollar amount requested to settle your entire personal injury claim: $ Dollar amount requested to settle your entire other damages claim: $ Total dollar amount requested to settle your entire claim: $ 4. EXPLANATION OF DAMAGES
Describe the damage to your property (if any) and the specific facts supporting the amount claimed. (Please attach all receipts and other documentation related to the damage amount claimed.) Describe your personal injuries (if any) and the specific facts supporting the amount claimed. (Please attach all receipts, medical bills and other documentation related to the injury amount claimed.) Describe your other damages (if any) and the specific facts supporting the amount claimed. (Please attach all receipts and other documentation related to the damage amount claimed.) Page 3 of 4
Rev 6/7/21
By signing your name below, you certify that the information provided is true and correct to the best of your knowledge and belief.
The city's acceptance and subsequent processing of your claim is not a waiver of the city's right to object to the sufficiency of the claim and should not be considered as an acknowledgment by the City that the claim is valid. To the extent city records need to be preserved, you are directed to A.R.S. 39-121, et seq. Claimant Name:
(Signature of Claimant)
Form Completed By:
(Print Name of Person Completing Claim Form for Claimant) Phone Number:
(Phone # of Person Completing Claim Form for Claimant) Address:
(Address of Person Completing Claim Form For Claimant) Relationship to Claimant:
Date:
PLEASE KEEP A COPY OF THE COMPLETED FORM FOR YOUR RECORDS INSTRUCTIONS FOR FILING YOUR CLAIM
Arizona Revised Statute §12-821.01 requires that this form must be filed with the City Clerk Department.
You can do so using one of the following three methods: 1. By physically delivering a copy of the claim form to: City of Phoenix
City Clerk Department
200 W. Washington Street, 15th Floor
Phoenix, AZ 85003
2. By emailing a copy of the claim form to: *******.****.*****.**********@*******.*** 3. By mailing a copy of the claim form to:
City of Phoenix
City Clerk Department
200 W. Washington Street, 15th Floor
Phoenix, AZ 85003
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