Risk Management Office

claims@charlottenc.gov

600 East Fourth St. 10th Floor Charlotte, NC 28202

704-336-3301

Auto Liability Claim Form

Phone Number

Exact Location of Accident: (include street no. and landmarks):

Date and Time of Accident

Tell us what happened

Was anyone injured?

Yes

Describe injuries

Describe Your Vehicle

Year

Make

Model

Tag No.

Type of Vehicle

Other (If damages other than a vehicle)

Location of Damage

Estimate Amount

Upload estimate and/or photos

Click Here to Upload

Describe Other Vehicle

Year

Make

Model

Tag No.

Unit No.

Type of Vehicle

Other entity

City

County

Board of Education

Location of Damage

Police Complaint No.

Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

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