NOTICE OF INJURY/DAMAGE

 

Return to: Town Clerk of the City of Hartford, 550 Main Street, Hartford, CT 06103

I, _______________________________of ____________________________________________________

(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

fully:

 

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 injury?

What direction were you traveling?

Had you traveled over this place before in the same direction?

Were you treated by a doctor? _______YES _______NO

Doctor's Name ___________________________________________________________________________

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

 

 

Signed ___________________________________________________

Recordings.doc-Susan