NOTICE OF TORT CLAIM

----------------------------------IMPORTANT NOTICE--------------------------------TO BE CONSIDERED,

YOUR CLAIM MUST BE SUBMITTED TO: CITY OF SANTA FE
RISK/SAFETY DIVISION
P.O. BOX 909
2651 SIRINGO ROAD,
BLDG J
SANTA FE, NM 87505
(505) 955-5621/FAX 955-5629
ALL TORT CLAIM NOTICES MUST BE SUBMITTED TO THE CITY OF
SANTA FE WITHIN NINETY DAYS AFTER OCCURRENCE.
CLAIMANT:_______________________________AMOUNT OF CLAIM:____________________
ADDRESS:_________________________________DATE OF ACCIDENT:____________________
___________________________________________PLACE OF ACCIDENT:___________________
PHONE NUMBERS: HOME:_______________________WORK:___________________________
CAUSE OF ACCIDENT:______________________________________________________________
___________________________________________________________________________________
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___________________________________________________________________________________
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HOW DID THE ACCIDENT OCCUR:__________________________________________________
___________________________________________________________________________________
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___________________________________________________________________________________
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LIST OF PERSONS/PROPERTY FOR WHICH YOU ARE CLAIMING DAMAGES:
1._______________________________________________ $_________________________________
2._______________________________________________ $_________________________________
PLEASE SUBMIT ANY ESTIMATES, BILLS OR OTHER INFORMATION YOU MAY HAVE
TO VERIFY THE AMOUNT OF YOUR CLAIM.
_____________________________________________________
________________________
SIGNATURE

DATE

ONCE YOU HAVE FILED YOUR NOTICE OF TORT CLAIM WITH THE CITY OF SANTA FE,
IT WILL BE SUBMITTED TO THE CITYS INSURANCE CARRIER FOR INVESTIGATION.