CITY OF CHICAGO CLAIM FORM
(Damage To Vehicle)

Please note: Title 2, Chapter 2-12, Section 2-12-060 of the
Chicago Municipal Code requires that all claims are typed.

Instructions: Complete this form online and then print it or
click here for the print only version of this form.


1. Claimant's Name: ,
(Last, First Middle)
2. Street Address:
3. City/State/Zip Code: / /
4. Telephone Number: - D - E
(Day and Evening)
5. Full Name of Claimants Insurance Company:
6. Name of Policy Holder:
7. Policy Number:
8. Policy Period: /
(From Date/To Date)
9. Claimant's Vehicle: Make:  Model:  Year: 
License Plate No.:  State Of License: 
10. Date & Time of Incident: --
11. Location at Which Accident Occurred:
(Street, Avenue or Boulevard/Number or Name of Closest Intersecting Street)
12. Name of Other Driver: ,
(Last, First Middle)
13. Vehicle License Number:
14. City Department for
Which Driver Works:
15. Name of Witness
to Accident:		 ,
(Last, First Middle)
16. Street Address:
17. City/State/Zip Code: / /
18. Telephone Number: - D - E
(Day and Evening)
19. Describe in Detail
How Accident Occurred:
20. Police Report Number:
20a. City Department
Report Number:
21. Two Written Estimates Attached: Yes         No
(Cost to Repair Damages)
22. Paid Bill
Attached:		 Yes         No
23. Signature of Claimant:
Date:

Have you?

Mail the completed form, along with any required supporting evidence to:

Office of the City Clerk
Attn: Claims 121 N. Lasalle St.
Room 107
Chicago, IL 60602-1295