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Notice of Property Damage, Personal Injury, Death

2. 
3. Notice of Property Damage, Personal Injury, Death
   City Attorney
5. Pursuant to the provisions of Section 2-521 of the Code of Ordinances of the City of Brownwood, notice of property damage, personal injury, or death shall within thirty (30) days of occurrence be reported in writing to the Mayor and City Council. All notices shall be effectuated by serving them upon the City Manager or City Secretary at City Hall, 501 Center Avenue, Brownwood, Texas.
7. To: Honorable Mayor and Members of the City Council Brownwood, Texas
9. From:
11. Name (Claimant):*
13. Address*
15. City, State, Zip:*
17. Home Phone:
18. Work Phone:
19. Cell Phone:
21. Property Owner and number if different than Claimant:
23. Date & time that injury or damage occurred to claimant:*
    Date & time that injury or damage occurred to claimant:

    Date & time that injury or damage occurred to claimant:
25. Location where injury or damage occurred:*
27. Police Investigation*
    -- Select One --NoYes
28. Attach Police Report
30. Nature and apparent extent of the damage or injury (Please specify and detail how and under what circumstances the damage or injury occurred):*
32. Amount for which claimant will settle:*
36. Name and address of treating physician and/or care facility (where applicable):
37. Name and address of treating physician and/or care facility (where applicable):
39. Witnesses to accident or loss:
40. Witnesses to accident or loss:
44. If automobile accident:
46. Vehicle Year:
47. Model:
48. VIN:
49. License Plate #:
51. Vehicle Owner
52. Address:
54. City, State, Zip
55. Phone Number:
56. Work or Other Phone Number:
60. Any other insurance coverage for this claim?
    -- Select One --NoYes
62. Insurance Company:
63. Policy Number:
65. Effective Date:
    Effective Date:
66. Phone Number:
68. Address or Agent:
72. I swear (or affirm) that the information contained in this Notice is true and correct. I fully understand that a complete and thorough investigation must be conducted by the City of Brownwood and/or its designated liability carrier of the allegations contained herein. I understand that submission of this claim is subject to the Open Records Act.
74. CLAIMANT or AUTHORIZED REPRESENTATIVE*
75. Sworn to this day:*
    Sworn to this day:
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

* indicates a required field