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TO: City of Suffolk - Risk Management
P.O. Box 1858
Suffolk, VA 23439
Office: 757-514405 Fax: 757-923-2531
email: riskmanagement@suffolkva.us
Person/Firm making claim (Full Name):*
Address:*
City & State*
Zip Code*
Email Address*
Contact Phone Number*
Type of claim being made (check):
1. Automotive Damage
1. Property Damage
1. Injury
1. Other
Date of Incident/Loss*
Date of Incident/Loss
Time of Incident Loss*
Time of Incident Loss
Location of Incident/Loss:*
Description of Incident/Loss*
Explain why you consider the City responsible:*
Was a City Official notified when the incident occurred? (such as Police, Public Works, Public Utilities, etc.)
1. Yes
1. No
If yes, to whom?
When?
Fill out all sides of form where necessary
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1

For Auto Damage (optional)
Vehicle Owner:
License #:
Make of Auto:
Model:
Year:
Do you have Insurance? (Check):
1. Yes
1. No
Carrier:
For Injury (optional)
Nature of Injury:
Were you treated? (Check)
1. Yes
1. No
Name and Address of Doctor/Hospital
Are you still under treatment? (Check)
1. Yes
1. No
By Whom?
Do you have health insurance? (Check)
1. Yes
1. No
By Whom?
Fill out all sides of form where necessary
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2

For Property Damage (optional)
Description of damage:
Is this property insured? (Check)
1. Yes
1. No
Carrier
Any additional information that you feel we should be aware of:
DOLLAR AMOUNT OF DAMAGES CLAIMED: *
This City of Suffolk Report of Incident is for your convenience and is not an acknowledgement of liability or waiver of rights by the City of Suffolk. Omission of facts may cause a delay or affect the outcome of the claim so please complete fully and in detail. If you have any written repair estimates and photos, please return with this form.
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You must sign form in order for the City to process the claim.
Instructions: Fill out this form and return to or email:

City of Suffolk
Risk Management
PO Box 1858
Suffolk, VA 23439
email: riskmanagement@suffolkva.us
Signature (required for processing of claim)*
Date*
Date
Return to: City of Suffolk - Risk Management Fax: 757-923-2531
P.O. Box 1858 E-mail: riskmanagement@suffolkva.us
Suffolk, VA 23439
Virginia Code § 15.2-209. Notice to be given to counties, cities, and towns of tort claims for damages. A. Every claim cognizable against any county, city, or town for negligence shall be forever barred unless the claimant or his agent, attorney, or representative has filed a written statement of the nature of the claim, which includes the time and place at which the injury is alleged to have occurred, within six months after such cause of action occurred. Failure to provide such statement shall not bar a claim against any county, city, or town, provided that the attorney, chief executive, or mayor of such locality, or any insurer or entity providing coverage or indemnification of the claim, had actual knowledge of the claim, which includes the nature of the claim and the time and place at which the injury is alleged to have occurred, within six months after such cause of action accrued. However, if the claimant was under disability at the time the cause of action accrued, the tolling provisions of§ 8.01-229 shall apply.

Any questions please contact Risk Management by phone 757‐514‐4025 or e‐mail riskmanagement@suffolkva.us

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Report of Incident & Claim Against the City

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