CITY AND BOROUGH OF JUNEAU (CBJ)

NOTICE OF CLAIM

This form should be filled out in as much detail as possible to assist the CBJ in evaluating your claim. Depending on the type of claim, we will either evaluate the claim in-house or forward to our adjusting company for review and investigation. How long it will take to adjust the claim and finalize a decision will depend on the complexity and nature of the accident/incident.

PERSON OR PERSONS MAKING CLAIM
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Email
Cell Phone
Home Phone
Work Phone
DATE, TIME, PLACE OF INJURY OR DAMAGE
Date
Time

: Hours

Minutes

AM/PM
Place/Location
PROPERTY INVOLVED
Description
If Vehicle (Year, Make, Model & License Number)
DEPARTMENT INVOLVED
Department (and/or vehicle number)
Municipal Employee
INJURED PERSON/PERSONS
Name
First Last
Telephone
Age
Address
Street Address City State / Province / Region ZIP / Postal Code
Occupation
Employed By
Person's location when injured
Person's activity when injured
How did injury occur?
Add another injured person?
- Yes
ADDITIONAL INJURED PERSON
Name
First Last
Telephone
Age
Address
Street Address City State / Province / Region ZIP / Postal Code
Occupation
Employed By
Person's location when injured
Person's activity when injured
How did injury occur?
AMOUNT CLAIMED
Amount Claimed ($)
DESCRIPTION
Nature and extent of injury or damages. Please describe in detail.
MANNER OF OCCURRENCE OF INJURY OR DAMAGES
Please explain in detail what happened and why you believe CBJ is liable.
WITNESSES
Include automobile passengers, Police, Doctors and all others having information concerning the claim.
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
SIGNATURE OF COMPLAINANT REQUIRED
I, the undersigned, do hereby submit, under oath to the City and Borough of Juneau, Alaska, this Notice of Claim for damages to my person or property. I do hereby intend to hold the CBJ liable for such damages claimed herein.
Name
First Last
Date
- Receipt of this form does not imply acceptance of liability. It is the means in which to enter a claim against the City and Borough of Juneau.
- Any person who, knowingly and with intent to deceive, submits a claim containing a false or deceptive statement may be found guilty of fraud.
If you have any supporting documents, please email to: [email protected].
CAPTCHA

Questions?

Contact:
Chelsea Swick, Risk Management Officer
Human Resources & Risk Management Department
[email protected]
Phone: (907) 586-5250
Fax: (907) 586-4502

CITY AND BOROUGH OF JUNEAU (CBJ)

NOTICE OF CLAIM

PERSON OR PERSONS MAKING CLAIM

DATE, TIME, PLACE OF INJURY OR DAMAGE

PROPERTY INVOLVED

DEPARTMENT INVOLVED

INJURED PERSON/PERSONS

ADDITIONAL INJURED PERSON

AMOUNT CLAIMED

DESCRIPTION

MANNER OF OCCURRENCE OF INJURY OR DAMAGES

WITNESSES

SIGNATURE OF COMPLAINANT REQUIRED

Questions?