City of Marlborough
marlborough, massachusetts 01752-3812
Office Of The City Clerk
City Hall, 140 Main Street, 1ST Floor
Tel. 508-460-3775 / fax 508-624-6504 / tdd 508-460-3610
FORM FOR CLAIM AGAINST THE CITY OF MARLBOROUGH
PLEASE PRINT. Once completed, please mail or deliver to the City Clerk’s Office at the address above.
Please allow 10-12 weeks for processing.
Name: _________________________________________ Date of Incident: _____________________________________
Address: _______________________________________ Time of Incident: _________________ a.m. p.m.
City: ____________________ State: ______ Zip: ______ Exact address where
incident occurred: _____________________________________
Phone (day): _____________Phone (eve): _____________ City:____________________________ State: ____ Zip: ______
It May Be Necessary That You Provide Evidence of Filing With Your
Insurance Carrier (Home, Auto or Other) About This Incident.
Check all that apply: [ ] Property [ ] Vehicle [ ] Personal [ ] Vehicle
[ ] Other Damage [ ] Personal Injury [ ] Accident [ ] Home
OTHER (explain) _____________________________________________________________
Describe what happened in as much detail as possible: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Describe property damage or personal injury:
______________________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________
Witnesses, Names, Addresses, Phone #: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Name of Medical facility, personnel (if applicable): _________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________
Estimate of property damage/personal injury (attach estimates, bills): ______________________________________________________________________________________________________________________________________________________________________________________________________
Attach anything else that will help to explain your claim (photos, sketches, etc.) Use additional pages if necessary.
THE CITY OR ITS INSURANCE COMPANY WILL CONDUCT AN
INVESTIGATION OF YOUR CLAIM TO DETERMINE LIABILITY.
You will be informed of our determination as soon as possible.
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