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2. Liability Claim Report

4. Claim for Damages

   If you have been involved in an incident or accident resulting in bodily injury and/or property damage and wish to file a claim against the Town of Huntersville, you will need to submit a written claim.

   Claim Process 

   Upon receipt of the claim, Human Resources staff will review the submitted information and contact you if any additional information is needed. Once all information is compiled, a claims adjuster from the Town’s third-party administrator will contact you, typically within 48 business hours from the date they receive the complete claim information. An investigation must be conducted by the claims adjuster before a final decision on liability and/or payment(s) will be made. There are many variables during the claim investigation, and this process can take up to 30 days or longer depending on the nature of your claim.  

   Liability and Legal Rights

   Following this procedure does not mean the Town of Huntersville is accepting liability for your claim. It does not waive any legal rights that you and/or the Town may be able to rely on. Sole authority to settle and/or pay claims rests with our third-party administrator. Employees are not authorized to determine liability or obligate the Town for payment of a claim. 

6. Today's Date*
   Today's Date
7. Date/Time of Incident*
   Date/Time of Incident

   Date/Time of Incident
9. Person Reporting Incident*
10. Email Address*
12. Address*
14. City*
15. State*
16. Zip Code*
18. Phone Number*
20. Location of Incident*
22. City*
23. State*
24. Zip Code*
26. Description of Incident/Incident*

    Share any facts concerning how and any circumstances under which injury/damage occurred.  Describe alleged defect.

28. Description of Damage*
30. Estimated Damages*

    Attach/send copies of original receipts or estimates for replacement.

31. Attach Documentation (pdf, jpeg, etc.)*
33. Name of Witness to Incident
34. Phone Number
36. Address
38. City
39. State
40. Zip Code
42. Name of Town department/employee with whom you have been in contact with regarding this incident
43. Police Report Number, if applicable
45. Were any injuries sustained?*

    1. Yes
    2. No
47. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
49. Electronic Signature
50. Date*
    Date

52. Please upload any evidence of the incident including photo(s) of damaged property, estimate(s) for replacement, police report (if applicable), and any other relevant information.

Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field