This form or other written notice of this incident must be received by the Town within thirty (30) days from the date of the incident.

Type of Incident*

Property Damage due to Sewerage Property Damage from Sidewalk Plow

Property Damage from Snow Plow Property Damage due to Other Circumstances

Are you the property owner?*

Yes

No

Your Contact Information

First Name*

Last Name*

Address Line 1*

Address Line 2

City/Town*

State*

Zip Code*

Day Telephone #

Evening Telephone #

Email Address*

Information about the Incident

Date of Incident(mm/dd/yyyy)*

Approximate Time

AM/PM

AM PM

Location of Incident*

Was this incident reported to the Town when it occurred?*

Yes

No

Was the incident reported to the Town before filing this claim?*

Yes

No

If the incident was reported to the Town, when (mm/dd/yyyy)?

Which department was the incident reported to?*

Department of Public Works DPW - Water and Sewer Division Fire Department Library Park and Recreation Police Department School Department Town Manager Other Town Department Was Not Reported

Name of the employee(s) you spoke to about this incident?

Explain the cause of the incident (please be as specific as possible)*

Description of Damage*

Estimated Repair Cost (provide source of estimate)

Upload a Document

Did you notify your insurance company?*

Yes

No

Name of the Insurance Company

Other Information Regarding the Incident

This property damage claim form may also be printed and mailed to: Town of Needham
Property Damage Claims
Department of Finance
Town Hall
1471 Highland Avenue
Needham, MA 02492

(revised 11/19/2018)