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:
8. Policy Period:
	(From Date/To Date)
9. Date & Time of Incident:
10. Describe in Detail Nature of Claim:
11. Name of Witness to Incident:
	(Last, First, Middle)
12. Street Address:
13. City/State/Zip Code:
14. Telephone Number:
	(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