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2. Claim Number
3. Adjuster
4. Date Claim Filed with Insurer
5. Status of Claim
9. Form Instructions
   Use this form to file reports to the City's Safety & Risk Management Division for the following types of incidents: property damage to City property, graffiti, City tree falling down and damaging property, reports of uneven sidewalks, potholes, other public safety hazards, etc.
11. Type of Claim*

    1. City Property Damaged
    2. Graffiti
    3. City Tree Caused Property Damage
    4. Sidewalk Trip Hazard

    1. Pothole
    2. Vehicle Accident
    3. Lost Property
    4. Other (explain below)
13. Time & Date of Loss*
    Time & Date of Loss

    Time & Date of Loss
15. Location of Incident*
17. Description of Incident*
    Please provide a thorough description of the incident. Written witness statements, police reports, photos and other supporting documents can be attached below
19. Responding Police Department*

    1. Rockville City
    2. Montgomery County

    1. Other
    2. No Police Responded
20. Police Report Number
22. Additional Information
23. Police Report
24. Photo
26. Photo
27. Photo
28. Witness Statement
30. Upload File - Photo
31. Upload File - Quote or Invoice
32. Upload File - Quote or Invoice
34. Your Name (First & Last)*
35. Your Email Address*
37. Your Phone Number or Extension*
38. Your Department
    -- Select One --City Attorney City ClerkCity ManagerCommunity Planning & Development ServicesFinanceHuman ResourcesInformation TechnologyPolicePublic WorksRecreation & Parks
40. Has the Unsafe Condition been Addressed?

    1. Yes
    2. No
    3. N/A
42. Please answer the questions below if this was a vehicle accident involving a City vehicle.
44. City Vehicle Number
45. Was Driver or Passenger Injured?

    1. Yes
    2. No
47. Description of Damage to City Vehicle
49. Was City Vehicle Towed?

    1. Yes
    2. No
50. Name and Contact Information for Other Driver Involved
52. You are required to submit to post-accident drug and alcohol testing if you were driving a City vehicle and involved in an accident, regardless of fault, and damage occurred to either the City vehicle, other vehicle involved or property damage of any kind. Please immediately contact the Human Resources Department at 240-314-8470 to schedule an appointment with Concentra to perform this testing. You are not authorized to operate City vehicles or equipment until the Safety & Risk Manager provides written authorization regarding your negative test results. This policy excludes the Police Department. The Police Department follow General Order policy 4-6.
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field