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Fill in all information regarding the person making the claim.
Fill out information regarding the accident or incident.
If applicable, please include the following information in your description: What injured person(s) was doing. What items were damaged. Description of damage. Tools, equipment, structures, or fixtures that were involved. How the City was involved.
Fill out information about any injuries related to your claim.
What part of the body was injured? Describe injury.
Please submit or attach any additional information that may be relevant in making a determination about this claim
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