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Citizen Claims Form

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City of Tampa - Citizen Claims Form

SUBMISSION OF A CLAIM DOES NOT GUARANTEE PAYMENT BY THE CITY

Date and location must be included and accurate to consider your claim

Name
Weather Conditions
Report to Police?
IF PROPERTY IS YOUR VEHICLE, INCLUDE BELOW INFORMATION
INJURY INFORMATION (If not applicable, enter N/A)
Injured Person Address
WITNESS INFORMATION
Claim Attachment(s) - Limited to 5 Attachments
Maximum 5 files.
5 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, .
18 MB limit per form.
Maximum 2 files.
5 MB limit.
Allowed types: gif, jpg, jpeg, png.
18 MB limit per form.
$

The information on this form is confidential information under Florida Statute 768.28.  Any person who knowing and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree (Florida Statute 626.8797).