2. Name (Property Owner or Injured Person)*
4. Email Address*
6. Street Address*
8. City*
10. State*
12. Zip Code*
14. Home Phone*
16. Cell Phone*
18. Work Phone
20. Date of Incident:*
22. Location of Event (Where Incident Occurred)*
24. Property Damaged and/or Injury Sustained*
26. Estimate Amount of Damage/Injury*
28. Describe incident in detail. Include verbatim statements of person(s) suffering injury or property damage, and witnesses. Ask key witnesses to write statements. State how you believe the City caused or contributed to the damage/injury. State nature and extent of injuries.*
30. Witness #1 Name
32. Witness #1 Address
34. Witness #1 Phone
36. Witness #2 Name
38. Witness #2 Address
40. Witness #2 Phone
42. Documentation

    1. Estimates
    2. Pictures
    3. Records
    4. Statements
    5. Other
44. Documentation Upload #1
46. Documentation Upload #2
48. Documentation Upload #3
50. Documentation Upload #4
52. Name of any city employee with knowledge of incident
54. If you need to send paperwork via mail, send to:
    Office of City Attorney
    PO Box 5503
    Bismarck ND 58506-5503
56. By submitting this claim form, I understand that I am asking the City of Bismarck to consider my claim for reimbursement.
58. The City will be reviewing the incident to determine whether it will offer payment to you for the loss.
60. Date*
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

* indicates a required field