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Claim Form

2. City of Hot Springs Claim Form
   Instructions: Complete this form clearly stating the reason for the claim, amount you are claiming, all contact information, and attach appropriate documentation including receipts, estimates, photos, etc. Substantive documentation (written estimates and/or receipts, proof of incident, etc.) MUST be provided to establish all monetary values. Additional sheets may be added. Failure to provide all information and fully substantiate your claim will result in the claim being rejected. Filing a claim does not imply approval; claims will be investigated before a decision is rendered. Claims containing inaccurate or fraudulent information will be rejected.

   Instructions: Complete this form clearly stating the reason for the claim, amount you are claiming, all contact information, and attach appropriate documentation including receipts, estimates, photos, etc. Substantive documentation (written estimates and/or receipts, proof of incident, etc.) MUST be provided to establish all monetary values. Additional sheets may be added. Failure to provide all information and fully substantiate your claim will result in the claim being rejected. Filing a claim does not imply approval; claims will be investigated before a decision is rendered. Claims containing inaccurate or fraudulent information will be rejected.

4. Please return all documents to:
   City of Hot Springs Attention: Claims<br>Dorethea Yates<br> 517 Airport Road Suite C<br> Hot Springs, AR 71902

   City of Hot Springs Attention: Claims
   Dorethea Yates
   517 Airport Road Suite C
   Hot Springs, AR 71902

6. Claimant Information

8. Full Name*

   (Last Name, First name, Middle Initial)

10. Email Address

12. Address

14. City

15. State

16. Zip

18. Incident Information

20. Address/Location of Occurrence*

22. Date and Time of Occurrence*

24. Amount Being Claimed*

26. Nature of Occurrence*
    -- Select One --Sewer BackupStreet RelatedWater RelatedOther

28. Do you have insurance which covers your damage in this incident?*

    1. Yes
    2. No

30. If yes, Deductible Amount

32. The City will not pay a claim in an amount exceeding a Claimant’s insurance deductible, if covered.

34. The undersigned hereby files a claim against the City of Hot Springs, Arkansas for the following reason (s): (Attach additional sheets if necessary)*

36. By signing below, I acknowledge that the above-provided information is true and correct to the best of my knowledge and belief.
    The City of Hot Springs requires that you certify your Claim Form by submitting an electronic signature. Type your name and click Confirm Signature.

    The City of Hot Springs requires that you certify your Claim Form by submitting an electronic signature. Type your name and click Confirm Signature.

38. Enter Electronic Signature and Date*

40. Shaded areas for City Staff only

42. DEPARTMENT RECOMMENDATION

    1. Approved
    2. Denied
    3. Modified

43. CITY MANAGER AUTHORIZATION

    1. Approved
    2. Denied
    3. Modified

45. Comments

46. Comments

48. Department Head Signature and Date

49. City Manager Signature and Date

51. Account Number

Leave This Blank:


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

    This field is not part of the form submission.

55. Submit Submit and Print

* indicates a required field