NOTICE OF INJURY/DAMAGE
Return to: Town Clerk of the City of Hartford, 550 Main Street, Hartford, CT
(Name) (Street, town and zip code)
Date of Birth __________________Sex ______ Social Security No.
Telephone No. (Home) _____________________(Work)
hereby give notice that on the _______ day of _____________, 20_____, at
_________ o'clock A.M./.P.M.
I sustained the following personal injury or property damage: (describe all
injuries and property damage
Amount of property damage/medicals: $ (Attach bills)
Witnesses: Name and Address:
Police at Scene: ____Yes ____No Officer's Name
The place was (describe location of defect as accurately as possible,
including which side of the street, how far from curb or edge of road, if no
curbing, and locating the defect in distance and direction from the nearest
adjoining property-house number-intersecting street, pole with number, etc.)
The defect consisted of (state accurately the nature and dimensions of the
defect, such as ice or snow or both, a hole, an obstruction, broken or raised
flag walk, etc)
The weather was
IMPORTANT: AN ACCURATE DESCRIPTION OF THE DEFECT, ITS LOCATION AND YOUR
INJURY IS NECESSARY FOR A SUFFICIENT NOTICE TO THE CITY
To the best of your knowledge, how long has the defect existed prior to your
What direction were you traveling?
Had you traveled over this place before in the same direction?
Were you treated by a doctor? _______YES _______NO
Were you under any doctor's care prior to this injury? _______YES _______NO
If yes, what were you being treated for?
I hereby petition the Court of Common Council for a hearing on my claim for
damages and authorize the City of Hartford to receive medical, hospital and wage
reports concerning this claim.
Dated at Hartford, Connecticut, this ________ day of ___________________, 20