Risk Management Office

claims@charlottenc.gov

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

704-336-3301

General Liability Claim Form

Phone Number

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

Date and Time of Incident

Weather at time of incident

Rainy

Clear

Dry

Icy

Windy

Tell us what happened

Was anyone injured?

Yes

Describe injuries

Witness Name/Address/Phone #:

Property damage?

Yes

Describe damages

Describe Your Vehicle

Year

Make

Model

Tag No.

Type of Vehicle

Police Complaint No.

Upload estimate, invoice, and/or photos

Click Here to Upload

Please provide Name and Phone Number of any other person or department with whom you have been in contact.

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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