New Submission

All claim notifications must be filed within 180 days of the date of injury, damage, or death; by filing electronically or sending to the City Secretary’s Office at:

City of Wylie
Attn: City Secretary's Office
300 Country Club Road, Building 100
Wylie, Texas 75098

Once a claim is received by the City, it is forwarded to the City’s insurance carrier for investigation to determine the City’s liability, if any. State Law provides that cities are immune from liability of certain activities and damages. If investigation and applicable laws determine the City of Wylie is, or is not liable, a letter of explanation will be provided to the claimant within 45 – 60 days of receipt of the claim.

Claimant Information

	First Name*field type single line	Last Name*field type single line	Email Address*field type email
row 1	First Name*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Last Name*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Email Address*field type email

Preferred Phone*field type single line
ex: 123-456-7890
Input blocked. Maximum character limit of 4000 characters reached.
Secondary Phonefield type single line
ex: 123-456-7890
Input blocked. Maximum character limit of 4000 characters reached.
Mailing Address*field type address
Business Name (if applicable)
Input blocked. Maximum character limit of 4000 characters reached.
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Business Namefield type single line

Claim Information

Date and Time of Incident*field type date
State when and the approximate time the damage and/or injury occurred:
Location of Incident*field type single line
State where the damage and/or injury occurred:
Input blocked. Maximum character limit of 4000 characters reached.
Police Report*field type radio button
Was a police report filed?
Police ReportNoYes
Police Report No.field type single line
State the report number, if known:
Input blocked. Maximum character limit of 4000 characters reached.
Incident Type*field type checkbox
Incident TypeBodily InjuryVehicle DamageProperty DamageOther
What happened?*field type multi line
Describe how the incident occurred:
Person Injured*field type checkbox
If not yourself, state the first and last name of the person injured:
Person InjuredSelfOther
Relationship*field type single line
Please state the other person's relationship to you:
Input blocked. Maximum character limit of 4000 characters reached.
Address of Other Person Injured*field type radio button
State the address of the other person injured, if different that your own:
Address of Other Person InjuredSame as aboveOther
Injury Description*field type multi line
Describe the injury:
Driver of Vehicle*field type checkbox
If not yourself, state the first and last name of the driver:
Driver of VehicleSelfOther
Relationship*field type single line
State the other person's relationship to you:
Input blocked. Maximum character limit of 4000 characters reached.
License Plate No.*field type single line
State the license plate number of the vehicle involved:
Input blocked. Maximum character limit of 4000 characters reached.
Last 4 Digits of VIN*(?)field type single line
State the last four digits of the Vehicle Identification Number of the vehicle involved:ex: 1234
Input blocked. Maximum character limit of 4000 characters reached.
Make*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Model*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Year*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Vehicle Damage Description*field type multi line
Describe the vehicle damage:
Property Owner*field type checkbox
If not yourself, state the first and last name of the property owner:
Property OwnerSelfOther
Address of Property*field type radio button
State the address of the property damaged, if different that above:
Address of PropertySame as aboveOther
Property Damage Description*field type multi line
Describe the property damage:
Any Other Informationfield type multi line
State any other details of your claim(s) for damages against the City:
Amount of Claim*field type currency
$If unknown, enter $0.00.
Photos, Estimates, or Invoicesfield type file upload
Attach any photos, estimates, or invoices:
Drop files here
You have reached the maximum file limit: .

Witnesses

List the full names and contact phone numbers of any witnesses:

	Namefield type single line	Phone No.field type single line
Row 1×	Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Phone No.field type single line ex: 123-456-7890 Input blocked. Maximum character limit of 4000 characters reached.	×

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Insurance Carrier Information

	Insurance Company Name*field type single line	Phone No.*field type single line
row 1	Insurance Company Name*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Phone No.*field type single line ex: 123-456-7890 Input blocked. Maximum character limit of 4000 characters reached.

Acknowledgement

This form must be signed and dated as an acknowledgement that all of the statements made in this claim are true and correct to the best of your knowledge.
Signature*field type signature
Date*field type date
Date will be captured on form submission

Verification failed. Please check the checkbox.

Notice of Claim Against City of Wylie

Claimant Information

Claim Information

Witnesses

Insurance Carrier Information

Acknowledgement