City of Ottawa, Kansas
Damage/Injury Claims Form
All items on this form must be completed. Insert the word “NONE” where applicable.
Claims for damages to or for loss or destruction of property or for personal injury against the City of Ottawa must be submitted in writing pursuant to Ordinance No. 2884-88 and K.S.A. 12-105b (d) (L. 1987, Ch. 353, Sec. 9).
Following receipt of this claim the City has 120 days to investigate the claim and then to approve or otherwise to settle it.
Unless the City denies all or part of your claim, you may not commence a lawsuit against the City of Ottawa under the Kansas Tort Claims Act. Your claim is deemed denied if no action is taken within 120 days following the filing of your claim.
Claims should be filed with: City Clerk
101 S Hickory St.
P.O. Box 60
Ottawa, KS 66067-0060.
If you do not fully understand your rights and duties in making this claim, you should consult an attorney.
Please provide all the information below. Please print legibly.
1. Claimant Information:
Name (include spouse if applicable)
Street and/or Mailing Address
City State Zip
Phone Alternate Phone Number
2. Insurance Coverage:
A. Do you carry accident insurance? Yes No
If yes, please provide the following:
Insurance Company Name (include Agent Name)
Street and/or Mailing Address
City State Zip
Phone Fax Number
B. Have you filed a Claim with YOUR Insurance Carrier as a result of this incident?
Yes No
If yes, is it Full coverage or deductible?
Full coverage Deductible
If Deductible, state amount: $
3. Claimant Attorney or Representative Information (If you have authorized any person to act on your behalf in settling this claim, provide the following information):
Name Relationship to Claimant
Street and/or Mailing Address
City State Zip
Phone Alternate Phone Number
Does notice by the City to the above person of action concerning your claim constitute notice to you?
Yes No
4. Name(s) and Address(es) of City Employee(s) Involved in Incident (if applicable):
Name
Street and/or Mailing Address
City State Zip
Phone Alternate Phone Number
Name(s) and Address(es) of City Employee(s) continued:
Name
Street and/or Mailing Address
City State Zip
Phone Alternate Phone Number
5. Location of Incident (if specific address is not known, give directions from nearest intersection or known address):
AM / PM
Day/Date of Incident Time:
7. Amount of Claim:
ACTUAL / ESTIMATE Property Damage: $
ACTUAL / ESTIMATE Personal Injury: $
ACTUAL / ESTIMATE Total: $
Attach any/all documentation if available.
8. Description of Incident: (State below in detail, all known facts and circumstances relating to the damage or injury to persons or property involved and the cause thereof)
9. Property Damage: (Describe kind and location of property and nature and extent of damage)
10. Personal Injury:
A. State nature and extent of injury which forms the basis of this claim:
B. If medical treatment was obtained as a result of the incident, provide the names of physician and medical treatment facility:
11. Witnesses to Incident: (Provide all names and addresses of any eyewitnesses, if applicable)
Name
Street and/or Mailing Address
City State Zip
Phone Alternate Phone Number
Witnesses to Incident continued:
Name
Street and/or Mailing Address
City State Zip
Phone Alternate Phone Number
12. Claimant’s Certification:
I certify that the amount of claims covers only damages and injuries caused by the incident above and agree to accept said amount in full satisfaction and final settlement of this claim.
Claimant’s Signature Date
13. City Clerk’s Certification:
Received in the Office of the City Clerk of Ottawa, Kansas:
City Clerk’s Signature Date Received
Comments:
Official Use Only:
File Started: Date:Received in HR by:
Submitted to City Attorney:Recorded in Log:
Documentation attached: Site Photos Eye Witness Reports
Estimates / Invoices Other
File Closed:Claimant Notified: