CITY OF CHICAGO CLAIM FORM
(Property Damage)

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. Date & Time of Incident: --
10. Describe in Detail Nature of Claim:

I have attached a separate sheet detailing the claim
11. Name of Witness to Incident: ,
(Last, First, Middle)
12. Street Address:
13. City/State/Zip Code: / /
14. Telephone Number: -D - E
(Day and Evening)
15. Police Report Number:
15a. City Department Report Number:
16. Two Written Estimates Attached: Yes         No
(Cost to Repair Damages)
17. Paid Bill Attached: Yes         No
18. Signature of Claimant: _________________________________________
                                      Date:

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