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City of Cleveland Pothole Claim Form

This document is a letter from the City of Cleveland Department of Law regarding claims instructions. It provides guidance to claimants on completing and submitting a claim form for incidents involving automobile damage, personal injury, or other property damage. Claimants are instructed to fully complete the claim form and include necessary documentation such as vehicle ownership records, medical bills, or repair estimates depending on the type of claim. Claims processing can take up to 90 days after the completed form and documents are received.

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Kaylyn Renee
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7K views5 pages

City of Cleveland Pothole Claim Form

This document is a letter from the City of Cleveland Department of Law regarding claims instructions. It provides guidance to claimants on completing and submitting a claim form for incidents involving automobile damage, personal injury, or other property damage. Claimants are instructed to fully complete the claim form and include necessary documentation such as vehicle ownership records, medical bills, or repair estimates depending on the type of claim. Claims processing can take up to 90 days after the completed form and documents are received.

Uploaded by

Kaylyn Renee
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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City of Cleveland

Frank G. Jackson, Mayor

Department of Law
Barbara A. Langhenry, Director
601 Lakeside Avenue, Room 106
Cleveland, Ohio 44114-1077
216/664-2800 – Fax: 216/664-2663
www.cleveland-oh.gov

Re: Claims Instructions

Dear Claimant:

Please find enclosed a City of Cleveland Claim form. Please complete and sign the form,
and return it to the City of Cleveland Department of Law, Claims Unit and
Attention: R. Smith. It is important to note that the Claims Unit cannot begin an
active investigation into your claim(s) until this form is completed and received by the
Claims Section.

If a portion of the form does not apply to your particular situation, please write not
applicable, or N/A. To adequately investigate your claim, it is essential that you
accurately provide the time, date and exact location of the incident.

If your claim involves automobile damages, you will need to submit the
following documentation below:

1. A copy of your automobile title, registration or lease contract is mandatory; no auto


claim will be processed without including this information.
2. Insurance coverage information, including a copy of the declarations page, is
mandatory for both full and liability coverage.
3. Include two (2) estimates of costs of repair or an itemized repair bill. Two estimates
are requested for claims involving a motor vehicle accident.
4. If you are claiming tire damage, the age of the tire and tire tread measurement are
mandatory. Tire tread measurements can be obtained from most service stations.
5. Police report or incident report, if applicable, is very helpful.
6. Photographs of the damages to your vehicle or tire(s) and of the alleged defect that
caused your damages are very helpful.
7. Any witness statements are optional.

Claim Form File #343, Rev. 3/2014


If your claim involves personal injury, please include the following:

1. For ‘Trip and Fall’ accidents you must include the nearest address of where you
fell. No claim will be processed without this information.
2. Copies of all medical reports including; doctor bills, hospital bills and pharmacy
receipts.

If your claim concerns property damage other than automobile, you will need to
submit the documentation below:

1. A copy of homeowner’s or property insurance policy, including proof of the


deductible amount.
2. A separate itemized list(s) of property damages.
3. Include a description of each item on the list, including brand name, serial number,
quantity lost, purchase date or age of the item and purchase price.
4. Attach all bills, receipts, and estimates concerning the described property.
5. If your claim is for property damage to your business, please submit proof of
business ownership and/or lease rights and responsibilities.
6. Any photographs of either damaged property or what allegedly caused it.

Please send these items along with your completed claim form to the City of
Cleveland, Department of Law, Claims Section, Attention: R. Smith, 601
Lakeside Avenue, Room 106, Cleveland, Ohio 44114-1077.

The completed claims package can also be submitted via facsimile to 216-664-2663 or
electronically to rsmith7@city.cleveland.oh.us.

Note: Where an insurance policy is applicable, it is important to note that an


individual must use their own insurance policy to cover their damages. A municipality,
such as the City of Cleveland, may reimburse the deductible; however, we are not
required to pay for damages that could possibly be paid by an insurance company. (See
Ohio Revised Code Section 2744.05).

Remember, your claim cannot be processed until the Claims Section receives a
completed claim form. Claims processing can take up to 90 days or more. You
will be contacted in writing as soon as your claim has been investigated and
fully processed.

Sincerely,

Rhonda R. Smith

Rhonda R. Smith
Claims Examiner

Claim Form File #343, Rev. 3/2014


City of Cleveland
Department of Law
Claim Form Claims Section
601 Lakeside Ave., Rm 106
Cleveland, Ohio 44114-1077

Phone: 216.664.2800 ­ Hours of Operation: 8 am to 5 pm Weekdays ­ Fax:


216.664.2663

If a portion does not apply to you, enter "not applicable" or N/A. Information can be computer-filled, or you can print out
the form and hand-fill it. Send completed form with required documents to the address above, Attn: R. Smith.
Completed claims package can also be faxed to 216.664.2663 or sent electronically to rsmith7@city.cleveland.oh.us.

NAME BIRTH DATE HOME PHONE WORK PHONE

STREET ADDRESS CITY STATE ZIP

EMAIL ADDRESS EMPLOYER NAME

INCIDENT DATE INCIDENT TIME ADDRESS OF INCIDENT

DETAILED DESCRIPTION OF INCIDENT

Police Report Made? ☐ NO ☐ YES If yes, where?


WITNESS NAME WITNESS ADDRESS

WITNESS NAME WITNESS ADDRESS

WITNESS NAME WITNESS ADDRESS

FOR CLAIMS CONCERNING VEHICLE DAMAGE OR AN AUTOMOBILE ACCIDENT


VEHICLE MAKE YEAR TYPE LICENSE NO.

OWNER’S NAME OWNER’S ADDRESS

DRIVER’S NAME DRIVER’S ADDRESS

Were you or anyone else injured? ☐ NO ☐ YES If yes, complete Personal Injury # People in Car:
section
NAME OF INJURED PERSON 1 ADDRESS

NAME OF INJURED PERSON 2 ADDRESS

NAME OF OTHER VEHICLE OCCUPANT 1 ADDRESS

NAME OF OTHER VEHICLE OCCUPANT 2 ADDRESS

AUTO INSURANCE COMPANY NAME MEDICAL INSURANCE COMPANY NAME

Claim Form File #343, Rev. 3/2014


ESTIMATED REPAIR COST DEDUCTIBLE AMOUNT DESCRIBE DAMAGE TO VEHICLE

FOR CLAIMS CONCERNING PERSONAL INJURY


NEAREST ADDRESS OF INCIDENT OCCURANCE

NATURE AND EXTENT OF YOUR INJURY

ATTENDING PHYSICIAN NAME ATTENDING PHYSICIAN ADDRESS

TOTAL MEDICAL EXPENSES TO DATE

TOTAL MEDICAL EXPENSES TO AMOUNT PAID BY INSURANCE AMOUNT PAID BY YOU AMOUNT OF WAGES LOST
DATE
$ $ $
$
HEALTH INSURANCE COMPANY NAME DEDUCTIBLE AMOUNT NAME OF HOSPITAL TRANSPORTED TO

LIST AND EXPLAIN ANY PHYSICAL DISABILITY

PROVIDE DATE AND NATURE OF ANY PRIOR INJURIES

FOR CLAIMS CONCERNING PROPERTY DAMAGE OTHER THAN AUTOMOBILE


CAUSE OF DAMAGE NAME OF CITY EMPLOYEE CONTACTED DATE

NAME OF PROPERTY INSURANCE COMPANY DEDUCTIBLE AMOUNT

I hereby attest that the above information is true to the best of my knowledge and belief:

Signature____________________________________ Date

ATTACHMENTS CHECKLIST

If claiming vehicle damage:


Declaration Page of car insurance policy showing deductible; copy of title, registration or lease contract; two written
estimates; police report, if applicable, and photographs of vehicle damage (helpful but not mandatory); and witness
statements, which are optional. If you are claiming tire damage, the age of the tire and tire tread measurements are
mandatory. Tire tread measurements can be obtained from most service stations.

If claiming personal injury:


Letter from employer outlining total amount of wage loss; copies of all medical reports including doctor bills, hospital bills
and pharmacy receipts; and witness statements (optional)

If claiming other property Damage:


A copy of homeowner’s or property insurance policy; including proof of the deductible amount; a separate itemized list(s)
of property damages with description of each item on the list, including brand name, serial number, quantity lost, purchase
date or age of the item and purchase price; bills, receipts, and estimates concerning the described property; photographs

Claim Form File #343, Rev. 3/2014


of either damaged property or what allegedly caused it; and witness statements (optional). If claim is for business property
damage, submit proof of business ownership and/or lease rights and responsibilities.

Claim No.

ITEMIZED PROPERTY DAMAGE CLAIM FORM


All bills, receipts, and itemized estimates must be attached.

DATE REPLACEMENT,
PROPERTY DESCRIPTION PURCHASE
QUANTITY BOUGHT OR RESTORATION
(Including brand name and serial #) PRICE OR REPAIR COST
AGE

Claim Form File #343, Rev. 3/2014

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