City of Victoria Form Center

2. Name*
3. Email Address
5. Address*
7. City
8. State
9. Zip Code
11. Phone Number*
12. Date & Time of Incident/Accident*
    Date & Time of Incident/Accident

    Date & Time of Incident/Accident
14. Location of Incident/Accident
16. Was there any construction at the location?

    1. Yes
    2. No
17. What type of loss are you claiming?

    1. Property Damage
    2. Personal Injury
19. Amount Claimed

    If you can provide an estimate, please send it via email to claims@victoriatx.gov.

21. Please Describe What Happened That Caused the Loss
22. List Any Witnesses and Their Contact Information
24. Were police called to the scene of the incident?

    1. Yes
    2. No
25. If Yes, Please Enter Police Report Number
27. Was a City employee involved in the incident?

    1. Yes
    2. No
28. If Yes, Please Include the Name of the City Employee
30. Do you carry insurance that may cover any part of this claimed loss?

    1. Yes
    2. No
31. If Yes, Please Provide Insurance Company Name, Agent, Phone Number, Deductible, Type (Home or Auto) and Policy Number
33. If you have any additional photos related to this claim, please send them via email to: claims@victoriatx.gov.

    If you have questions regarding your claim, please call the City's HR/Safety Department at 361-485-3500.

35. Photo
36. Photo 2
38. Additional Documentation/Photo
39. Estimates

    Please upload your estimate if available.

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field