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2. This form or other written notice of this incident must be received by the Town within thirty (30) days from the date of the incident.
6. Type of Incident*

   1. Property Damage due to Sewerage
   2. Property Damage from Sidewalk Plow
   3. Property Damage from Snow Plow
   4. Property Damage due to Other Circumstances
8. Are you the property owner?*

   1. Yes
   2. No
10. Your Contact Information
12. First Name*
14. Last Name*
16. Address Line 1*
18. Address Line 2
20. City/Town*
22. State*
24. Zip Code*
26. Day Telephone #
28. Evening Telephone #
30. Email Address*
34. Information about the Incident
36. Date of Incident(mm/dd/yyyy)*
38. Approximate Time
40. AM/PM
    -- Select One --BlankAMPM
42. Location of Incident*
44. Was this incident reported to the Town when it occurred?*

    1. Yes
    2. No
46. Was the incident reported to the Town before filing this claim?*

    1. Yes
    2. No
48. If the incident was reported to the Town, when (mm/dd/yyyy)?
50. Which department was the incident reported to?*
    -- Select One --BlankDepartment of Public WorksDPW - Water and Sewer DivisionFire DepartmentLibraryPark and RecreationPolice DepartmentSchool DepartmentTown ManagerOther Town DepartmentWas Not Reported
52. Name of the employee(s) you spoke to about this incident?
54. Explain the cause of the incident (please be as specific as possible)*
56. Description of Damage*
58. Estimated Repair Cost (provide source of estimate)
60. Upload a Document
62. Did you notify your insurance company?*

    1. Yes
    2. No
64. Name of the Insurance Company
66. Other Information Regarding the Incident
70. This property damage claim form may also be printed and mailed to: Town of Needham
    Property Damage Claims
    Department of Finance
    Town Hall
    1471 Highland Avenue
    Needham, MA 02492

    (revised 11/19/2018)
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit Submit and Print

* indicates a required field