City of Victoria Claim Form

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Please correct the field(s) marked in red below:

The Charter of the City of Victoria provides that written notice of claims for personal injuries or property damage must be submitted to the City within six months after the injuries or damages occur.

Acceptance of a claim by the City does not constitute an admission of liability.


1
Your Name
 *
2
Your Address
 *
3
Your phone number
 *
4
Your email address
5
Date & Time of Incident/Accident
 *
Date & Time of Incident/Accident
6
Location of Incident/Accident
7
Was there any construction at the location?
Was there any construction at the location?
8

What type of loss are you claiming?

What type of loss are you claiming?
9

Amount claimed (if you can provide an estimate, please send it via email to bbaugh@victoriatx.org):

 *
10
Please describe what happened that caused the loss:
11
List any witnesses and their contact information:
12
Were police called to the scene of the incident?
Were police called to the scene of the incident?
13
If yes, please enter PD Report #
14
Was a City employee involved in the incident?
Was a City employee involved in the incident?
15
If yes, please include the name of the City employee:
16
Do you carry insurance that may cover any part of this claimed loss?
Do you carry insurance that may cover any part of this claimed loss?
17
If yes, please provide insurance company name, agent, phone number, deductible, type (home or auto) and policy number:
18
If you have any photos related to this claim, please send them via email to: bbaugh@victoriatx.org.
If you have questions regarding your claim, please call the City's Legal Department at (361) 485-3520.
  1. To receive a copy of your submission, please fill out your email address below and submit.