AAA TEST

Title:

First Name:

M.I. :

Last Name:

Address:

City:

State:

Zip Code:

Email Address

Please enter a phone number for any of the following that apply

Home Number

Cell Number

Other Number

* Please confirm the accuracy of these statements

By checking this box,

.

I Do
I Don't

, confirm that the following statements are true and correct to the best of my knowledge on this day of

* CLAIM FOR INJURY

In the next section describe in your own words where, when, and how the damage or injury occurred. Attach additional pages if necessary. Give names and addresses of others involved and/or witnesses, if known.

* LOCATION OF LOSS (Please be specific)

DATE AND TIME OF OCCURRENCE

.

.

AM
PM

* Description of how damage or injury occurred

* Attach legible copies of all medical reports, medical bills and/or estimates of damages regarding this loss.

Description Here

* File must be less than 20 MB (only PDFs or images). Please click the SELECT button to add your document(s)

File

If known, the TOTAL amount of your claim against the CITY OF MCALLEN is, AND the POLICE CASE NUMBER (if known):

( Please be Specific )

NOTE: After your claim is received, it will be processed for service/handling.

Should you have any questions regarding your claim, please contact:

Risk Management Department
City of McAllen
P.O. Box 220, 78505
McAllen, Texas 78501
(956) 681-1425

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