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CITIZEN CLAIM FORM NOTICE REQUIRED: Any person claiming to have suffered an injury or property damage by a public entity or by an employee thereof, While the course of their employment, shall file a written notice as provided by the COLORADO REVISED STATUTES, Section 24-10-109, within one hundred eighty two (182) days after the date if the discovery of the injury or damage. CLAIM INFORMATION NAME AND ADDRESS OF THE CLAIMANT AND ATTORNEY IF ANY: Claimant Name: Address: Street City State Zip Phone: Email: Attorney: (if applicable) Name: Phone: Address: Street City State Zip Concise statement of the basis of the claim: Date of the Incident: AM PM Month Day Year Address: Street City State Zip Brief description of the incident: Why do you believe the City was responsible for the incident? Name, address, and phone number of any public employee involved, if known: Name: Phone: Address: Street City State Zip BODILY INJURY CLAIMS Name of Injured: Date of Birth: Phone (home): Phone (work): Nature of the Injury: Estimated Expenses: $ MOTOR VEHICLE CLAIMS Citizen Vehicle: Year: Make: Model: License Driver’s Name: Driver’s License Driver’s Phone (home): Driver’s Phone (work): Insurance Co: Insurance Describe City Vehicle: Driver’s Name: Department: ---PAGE BREAK--- Estimated Damage: $ Police Report PROPERTY DAMAGE Type of Property Damaged (ie: building, equipment, etc.): Describe damage: Estimated Damage: $ SIGNATURE (Required) I understand that submitting this claim form does not signify an admission of liability by the City of Arvada. By checking this box and typing my name below, I am electronically signing this claim form. □ Signature: Date: Email this form to: [EMAIL REDACTED] or Mail to: City of Arvada Risk & Safety Management 8101 Ralston Rd. Arvada, CO 80002 SIGN