| |
Risk Management Related Areas
|
BOTH SIDES OF THIS FORM MUST BE COMPLETED Please type or print Full Name: __________________________________________________________________________ Mailing Address: ______________________________________________________________________ Home Address: ______________________________________________________________________ City: ________________________________ State: _____ Zip Code: ___________________________ Home Phone Number: _______________________ Work Phone Number: _______________________ Date / Time of Incident: _______________________________________________________________ Auto Insurance Company____________________________________Ph#_______________________ Home Owner Insurance Co.__________________________________Ph#_______________________ Location of Incident: __________________________________________________________________ (be specific) ___________________________________________________________________________________ ___________________________________________________________________________________ The total amount of your claim against the City is $__________________________________________ Provide the details of your claim against the City. Describe in your own words, where, when, and how the damage or injury occurred. Attach additional sheets if necessary. Give names, addresses, and phone numbers of others involved or witnesses of the incident, if known. Attach copies of any bills, estimates, photographs, medical reports, etc., if applicable. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ All of the statements made in this claim are true and correct. Date: ___________________ Signature of Claimant: _________________________________ Section 11.06 of the Charter of the City of Lewisville requires written notice before any claim for injury or damage may be considered. A copy of the Charter Provision has been included with this claim form, for your information. Please read, sign, and return the Charter Provision with this claim form. Thank you. City of Lewisville Notice of Claim City Charter Provision Notice Section 11.06. Special provisions covering damage suits, etc. a. The City of Lewisville, Texas, shall never be liable for any personal injury, whether resulting in death or not, unless the person injured, or someone in his behalf, or, in the event the injury results in death, the person or persons who may have a cause of action under the law by reason of such death injury, shall file a notice in writing with the City Manager or City Secretary within one hundred eighty (180) days after the occurrence of such injury, stating specifically in such notice, when, where, and how the exact injury occurred, and the full extent thereof, together with the amount of damage claimed or asserted. The City of Lewisville, Texas, shall never be liable for claim for damage or injury to personal property unless the person whose personal property has been injured or damaged, or someone in his behalf, shall file a claim in writing with the City Manager or the City Secretary within one hundred eighty (180) days after said damage or injury has occurred, stating specifically when, where, and how the injury or damage occurred and the full extent thereof, and the amount of damage sus-tained. b. The City of Lewisville, Texas, shall never be liable for any claim for damage or injury to real property caused by the negligent act or omission of its officers, servants, or employees, unless the person whose real property has been injured or damaged, or someone in his behalf, shall file a claim in writing with the City Manager or City Secretary within one hundred eighty (180) days after said damage or injury has occurred, stating specifically when, where, and how the injury or damage occurred, and the amount of damage claimed. The City of Lewisville, Texas, shall never be liable on account of any damage or injury to person or to personal property arising from or occasioned by any defect in any public street, highway, alley, grounds or public work of the City of Lewisville, Texas, unless the specific defect causing the damage or injury shall have been actually known to the City Manager at least twenty-four (24) hours prior to the occurrence of the injury or damage, and proper diligence has not been exercised to rectify the defect. The notice herein required to be given to the City Manager or the City Secretary of the specific defect causing the damage or injury shall apply where the defect arose from any omission of the City itself, through its agents, servants or employees, or acts of third parties. c. No provision of this section shall ever be so construed as to expand the ordinary liability of the City; and provided, that nothing herein contained shall be construed to mean that the City of Lewisville, Texas, waives any rights, privileges, defenses or immunities in tort actions which are provided under the common law, the constitution, and general laws of the State of Texas. (Amend. elec. 5-5-8) State law reference-Tort claims, notice, V.T.C.A., Civil Practice and Remedies Code §101.101. I have read the above provision of the City of Lewisville Charter. Date: ___________________ Signature of Claimant: _________________________________ |
| ©City of Lewisville All Rights Reserved | Thank you for your interest in Lewisville, TX | Privacy Policy, ADA Compliance |
| CONTACT US | ||
| 151 W. Church Street 972-219-3400 - Phone 972-219-3410 - Fax | ||