Notice of Claim Form

Notice of Claim Form
Under Utah law, an injured party, or the owner of damaged property, or their legal representative must properly file a Notice of Claim against a governmental entity in order for a loss to be considered. A claim must include a brief statement of the facts, the nature of the claim asserted and the damages as far as they are known. The written claim must be signed, dated and submitted to the correct address or email addresses for the entity against which the claim is being made (see UCA § 63G-7-401).

Please complete all of the pertinent parts of the following form. You may attach additional documentation to your Notice of Claim such as photos, estimates, witness statements and the like; however, these items can be submitted later in the claim process.
Additional Instructions

Processing: Once your claim is received, an adjuster will be assigned, and they will contact you. Processing maytake some time. It is your responsibility to mitigate your damages. For questions, please call (800) 842-6172.

Medicare Eligibility: Federal law requires all entities that are responsible to pay for medical treatment, or whosettle bodily injury claims for eligible individuals, to report the obligation and settlements to Medicare. Reportingis required for the following individuals:
- Current Medicare beneficiaries, and
- Individuals who may be Medicare eligible within the next 30 months because they are: 62 ½ yearsold, have applied for SSDI, or have End Stage Renal Disease.
If you fit into one of these categories and are filing a claim for injuries, you will be required to furnish additional information in order to process your claim.

This procedure and use of this form for filing a claim is not to be construed as a waiver of any provision of the Utah Governmental Immunity Act. Submission of this Notice of Claim form does not guarantee compliance with the Act (UCA § 63G-7-101).

Your Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Loss Information
Date of Loss*

MonthDayYear
Date
Time of Loss*

Hour Minutes

AM/PM Option
Location*
Was your vehicle involved?*

YesNo
Vehicle Year
Vehicle Make
Vehicle Model
Was a City Employee Involved?*

YesNo
City Employee Name
City Vehicle Involved, if applicable.
Year, Make, Model, License Plate
Did Law Enforcement Respond?*

YesNo
Law Enforcement Agency
Case Number
Have you filed a claim with your insurance?*

YesNo
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.
Insurance Policy Number
Claim Number

Incident Information
Description of the Incident:*
Damages Incurred*
Injuries Incurred
Upload Additional Documentation Here

Pictures, estimates, witness statements, etc.
Cancelof
Signature*

Clear
Should be Empty:

Notice of Claim Form

Your Information

Loss Information

Incident Information