Claim Forms

2. NOTICE OF CLAIM AGAINST THE TOWN OF PRESCOTT VALLEY
4. The undersigned submits the following information and makes claim against the Town of Prescott Valley, and/or employee (enter name below) as follows.
6. CLAIMANT INFORMATION
8. First Name*
9. Last Name*
11. Address1*
13. Address2
15. City*
16. State*
17. Zip*
19. Phone (Home)*
20. Phone (Work)
21. Date of Birth*
23. OCCURRENCE OR EVENTS GIVEN RISE TO CLAIM
25. Date of Occurrence*
26. Time of Occurrence*
28. Location of Occurrence*
30. Provide specifics of the occurrence, event, act, or omission that you claim caused your injury or damage.*
32. Describe how or why you believe the Town or employee was at fault.*
34. Was this a vehicle accident?*

    1. Yes
    2. No
36. If this was a vehicle accident, state what road or highway on which the accident occurred.
38. Your vehicle license plate number
40. Year
41. Make
42. Model
44. License Plate of Town Vehicle
45. Name of Town driver
47. Was a Police report filed?

    1. Yes
    2. No
    3. I Don't Know
48. Police agency involved
50. Description of Property Damage and Injuries
52. Describe the property that was damaged.*
54. Dollar amount of property damage claimed.
56. Describe the personal injuries suffered.*
58. Dollar amount for which you would settle your personal injury claim.*
59. Attach receipts or other documentation of the amounts claimed. Attach medical reports where available.
61. Total Amount for which you would settle all property damage and Personal injury claims relating to this incident.*
63. WITNESSESS
65. List all witnesses, with their name(s), address and phone number*
67. Are there any additional comments, details, or information you want us to consider in responding to your claim?
69. By signing/entering your name below, you verify the information presented in this claim is true to the best of your knowledge and belief.
71. Signature /s/:*
72. Today's Date*
    Today's Date
74. Please fill in all information requested above or your notice of claim may be deemed defective. All notices must be signed and dated. The Town must also indicate above, the date and time received.

    
    

    
    

    THE ARIZONA MUNICIPAL RISK RETENTION POOL AND SOUTHWEST RISK SERVICES ARE NOT AUTHORIZED AGENTS TO RECEIVE ANY NOTICE OF CLAIM UNDER A.R.S. §12-821.01. ALL NOTICES OF CLAIM MUST BE LEGALLY SERVED ON THE TOWN AND ON EACH INDIVIDUAL WHOM YOU CLAIM TO BE RESPONSIBLE FOR YOUR INJURIES OR DAMAGES. THIS FORM WAS CREATED FOR YOUR CONVENIENCE. HOWEVER, THE TOWN THAT IS PARTY TO THIS MATTER DOES NOT WAIVE ANY OF ITS RIGHTS OR DEFENSES FOR YOUR FAILURE TO COMPLY WITH ALL NOTICE OF CLAIM REQUIREMENTS ESTABLISHED BY ARIZONA STATUTE AND LAW. UNDER A.R.S. §12-821.01, YOU ARE REQUIRED TO STATE YOUR DAMAGES WITH A SPECIFIC DOLLAR AMOUNT FOR WHICH YOU WILL SETTLE YOUR CLAIM AND, TO SUPPORT THAT AMOUNT WITH EVIDENCE. YOUR NOTICE OF CLAIM WILL BE DEEMED DEFECTIVE WITHOUT THIS INFORMATION.

76. FOR OFFICE USE: Notice of Claim Received By
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78. 1. Receive an email copy of this form.
79. Email address

    This field is not part of the form submission.

80. Submit

* indicates a required field

2. SOLICITUD DE INDEMNIZACION CONTRA EL PUEBLO DE PRESCOTT VALLEY
4. El firmanate somete la informacion suguiente y hace demanda contra el pueblo de Prescott Valley y/o empleado a lo siguiente.
6. INFORMACION DEL DEMANDANTE
8. Nombre del Demandante*
10. Domicilio*
12. Domicilio 2
14. Cuidad*
15. Estado*
16. Zip*
18. Numero de Telefono (Casa)*
19. Numero de Telefono (Trabajo)
20. Fecha de Nacimiento*
22. ACONTECIMIENTO DE DEMANDA
24. Fecha de Acontecimiento*
25. Hora*
27. Donde Occurio*
29. Dar especificos del aconticimiento, suceso, acto o omission que usted determina que causo su lesion or deterioro (dano)*
31. Describir como o porque usted cree que la ciudad/el pueblo o empleado estaba en falta *
33. Si este era un accidente de vehiculo, en que carretera ocurrio el accidente.
35. Matricula de su vehiculo
37. Ano
38. Marca
39. Modelo
41. Matricula del vehiculo de el pueblo
42. Nombre del conductor de el pueblo
44. Se hizo un informe policial?*

    1. Si
    2. No
    3. No Se
45. Distrito policial
47. DESCRIPCION DE DANO A PROPIEDA O LESIONES PERSONALES
49. Describir la propiedad que era estropeada*
51. Cantidad en dolares de deterioro de propiedad demandad
53. Describir las lesions personales demandadas*
55. Cantidad en dolares de lesiones sufridas*
56. Sujete recibos, cobros o otra documentacion en dolares que se cobra. Sujete informes medicos si es requerido.
58. Total de Demanda *
60. TESTIGOS
62. Liste todos los testimonios, con sus nombres, numero de telefono y domicilio.*
64. Hay algunos comentarios adicionales?
66. Firmando, usted comprueba la informacion presentada en esta demanda es verdadera a su mejor conocimiento y creencia.
68. Firma /f/:*
69. Fecha de hoy*
    Fecha de hoy
71. Por favor complete toda la información solicitada arriba o su notificación de reclamo podría considerarse defectuosa. Todos los avisos deben estar firmados y fechados. Prescott Valley también deberá indicar la fecha y hora de recepción.

    
    

    
    

    THE ARIZONA MUNICIPAL RISK RETENTION POOL AND SOUTHWEST RISK SERVICES ARE NOT AUTHORIZED AGENTS TO RECEIVE ANY NOTICE OF CLAIM UNDER A.R.S. §12-821.01. ALL NOTICES OF CLAIM MUST BE LEGALLY SERVED ON THE TOWN AND ON EACH INDIVIDUAL WHOM YOU CLAIM TO BE RESPONSIBLE FOR YOUR INJURIES OR DAMAGES. THIS FORM WAS CREATED FOR YOUR CONVENIENCE. HOWEVER, THE TOWN THAT IS PARTY TO THIS MATTER DOES NOT WAIVE ANY OF ITS RIGHTS OR DEFENSES FOR YOUR FAILURE TO COMPLY WITH ALL NOTICE OF CLAIM REQUIREMENTS ESTABLISHED BY ARIZONA STATUTE AND LAW. UNDER A.R.S. §12-821.01, YOU ARE REQUIRED TO STATE YOUR DAMAGES WITH A SPECIFIC DOLLAR AMOUNT FOR WHICH YOU WILL SETTLE YOUR CLAIM AND, TO SUPPORT THAT AMOUNT WITH EVIDENCE. YOUR NOTICE OF CLAIM WILL BE DEEMED DEFECTIVE WITHOUT THIS INFORMATION.

73. FOR OFFICE USE: Aviso de Demanda Recibida por
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75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

* indicates a required field