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CITY OF LEWISTON, MAINE INCIDENT REPORT Name Address Home Telephone # Work Telephone # Location of Incident Date & Time of Incident Type of Property Damaged (ie: bodily, vehicle, building, etc.) Describe Damage Disclaimer: Your submission of this claim does not automatically assure payment by the city. Each claim will be examined on its own merit by the insurance company representing the city. If Vehicle Damaged: Vehicle ID Year, Make, Model Vehicle License Plate # Driver of Vehicle (Name, Address & License Owner of Vehicle (Name, Address & License Witnesses: (Names, Addresses & Telephone City Vehicle involved? * Please provide any bills, estimates, police reports and photos for submission to our insurance. Signature: Date: