City of Coeur d'Alene - City of Coeur d'Alene Notice of Tort For Damage or Injury

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City of Coeur d'Alene Notice of Tort For Damage or Injury

This form is to be completed by the claimant and is a requirement that if used, be presented to and filed with the clerk of the public entity involved. This form is being provided as a courtesy to assist you in filing your claim. Providing this form to you is not an admission nor shall it be construed to be an admission of liability or an acknowledgement of the validity of a claim by the political subdivision. Legal requirements for filing claims can be found in the Idaho Code: Title 6, Chapter 9. All claims must be filed promptly and in writing.

Name:

Phone:

Address:

City:

State:

Zip:

Address for the Six (6) Months Prior to th e Date the Damage or Injury Occurred:

Date of Incident:

Time:

Location of Occurrence:

Injuries that Resulted:

Provide a description of what happened:

Attachment:

Attach any additional information you deem necessary

Attachment:

Attach any additional information you deem necessary

Names and addresses of all witnesses or others involved:

Reason for claim:

Amount:

I certify that my name typed in the signature box below shall serve as my signature, and I hereby certify that I have read the above information and it is true and correct to the best of my knowledge, and I am the person entitled to make this claim.

Signature: