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2. CONTACT INFORMATION

   Please provide contact information for the individual the Town should contact regarding this incident.

4. First Name*
5. Last Name*
7. Email Address*
8. Phone Number*
9. Fax Number
11. Address*
13. City*
14. State*
15. Zip Code*
19. INCIDENT INFORMATION
21. Type of Claim*
    -- Select One --Vehicular CollisionPersonal InjuryProperty DamageRoad/Sidewalk Defect

    Please Select the kind of claim you are making

22. Incident Date/Time*
    Incident Date/Time

    Incident Date/Time

    If the exact time is not known, approximate.

24. Address (Location of Incident)*
26. City*
27. State*
28. Zip Code*
30. Description of Incident:*
34. Attachments
36. Attachments
38. Attachments
40. Attachments

    Please attach any photographs, estimates, reports, or other relevant documents.

Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field