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