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2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
13. WHEN did damage occur?*

    Give full particulars, date and time of day:

15. WHERE did the damage occur?*

    Describe fully and indicate on the attached sheet.

17. INDICATE weather conditions. When rain commenced and ended, if applicable.*
19. HOW did damage occur? Give full explanation.*
21. NAMES of City employees alleged to have caused the damage or loss, if known.
23. WHAT DAMAGE OR INJURIES do you claim resulted? Complete attached Damage List.*
25. Did City crews investigate this claim?*

    1. Yes
    2. No
26. If yes, give the names of the City Employees, if known.
28. Substance of conversation with City crews, if any
30. Depth of water
31. Type of water (clear, muddy, etc.)
33. Was there sewer odor in your residence?
34. Do your basement drains contain backflow valves?

    1. Yes
    2. No
36. Does your residence or basement contain footing drains?

    1. Yes
    2. No
38. Have you had prior back-ups or sewer water problems?

    1. Yes
    2. No
40. If yes, state when and Describe.
42. Did water seep through the foundation walls?

    1. Yes
    2. No
43. If yes, describe extent
45. Did you call the City with reference to this claim?

    1. Yes
    2. No
46. If yes, when?
48. When was the last time that your private sewer laterals were rodded or cleaned?
    When was the last time that your private sewer laterals were rodded or cleaned?

    When was the last time that your private sewer laterals were rodded or cleaned?

    Provide an estimated date if actual date is not known. 

49. By whom?
51. TOTAL AMOUNT CLAIM*
53. Insurance payments, if any, and name of insurance company:
55. If signer of this claim is not the claimant, explain the relationship:
57. Please include additional information that may be helpful in resolving this claim, such as repair estimates and photographs.
59. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
61. Electronic Signature
Leave This Blank:


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

    This field is not part of the form submission.

65. Submit

* indicates a required field