Proper notice must be received by the Town within 30 days from the date of the incident.

Vehicle Damage Due to Pothole or Other Roadway Obstruction

This incident was related to:*

Pothole

Other Roadway Obstruction

Description of the “Other Roadway Obstruction”, if applicable.

Vehicle speed when the incident occurred?*

Incident Date*

Approximate Time

AM/PM

AM PM

Location of the Incident

Please be as specific as possible, i.e, street name, nearest address number, direction of travel

Nearest Cross Road

Please explain what happened and how.

Vehicle Information

Vehicle Year*

Vehicle Make*

Vehicle Model*

Registration Number*

Plate Number Color

Registration Type*

Passenger Commercial Motorcycle Other

State of Vehicle Registration*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Are you the vehicle owner?*

Yes

No

Your Contact Information

First Name*

Middle

Last Name*

Address*

Address 2

City/Town*

State*

Zip Code*

Telephone

Email*

Repair Cost (please provide the source for the estimate)

Supporting Document

Have you notified your insurance company?*

Yes No

Insurance Company

This vehicle damage claim form may also be printed and mailed to:

Town of Needham
Vehicle Damage Claims
Department of Finance
Town Hall
1471 Highland Avenue
Needham, MA 02492

(revised 02/07/2012)