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2. 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. This form is to be used only to report damage to private property. Damage to public property should be reported through https://seeclickfix.com/needham

4. 
   
6. Type of Incident*

   1. Private Property Damage due to Sewerage
   2. Private Property Damage from Sidewalk Plow
   3. Private Property Damage from Snow Plow
   4. Private Property Damage due to Other Circumstances
8. 
   
10. Are you the property owner?*

    1. Yes
    2. No
12. 
    
14. Your Contact Information
16. 
    
18. First Name*
20. Last Name*
22. Address Line 1*
24. Address Line 2
26. City/Town*
28. State*
30. Zip Code*
32. Day Telephone #
34. Evening Telephone #
36. Email Address*
38. 
    
40. Information about the Incident
42. 
    
44. Date of Incident(mm/dd/yyyy)*
46. Approximate Time
48. AM/PM
    -- Select One --AMPM
50. 
    
52. Location of Incident*
54. 
    
56. Was this incident reported to the Town when it occurred?*

    1. Yes
    2. No
58. 
    
60. Was the incident reported to the Town before filing this claim?*

    1. Yes
    2. No
62. 
    
64. If the incident was reported to the Town, when (mm/dd/yyyy)?
66. 
    
68. Which department was the incident reported to?*
    -- Select One --Department of Public WorksDPW - Water and Sewer DivisionFire DepartmentLibraryPark and RecreationPolice DepartmentSchool DepartmentTown ManagerOther Town DepartmentWas Not Reported
70. 
    
72. Name of the employee(s) you spoke to about this incident?
74. 
    
76. Explain the cause of the incident (please be as specific as possible)*
78. Description of Damage*
80. Estimated Repair Cost (provide source of estimate)
82. 
    
84. Upload a Document
86. 
    
88. Did you notify your insurance company?*

    1. Yes
    2. No
90. 
    
92. Name of the Insurance Company
94. 
    
96. Other Information Regarding the Incident
98. 
    
100. 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 03/05/2025)
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102. Submit Submit and Print

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