Risk Management Center Claim Form

2. Liability - Auto - Property Loss Notice Form
3. Town of Madison, Connecticut
4. Risk Manager
   Lauren Rhines 8 Campus Drive Madison, CT 06443 rhinesl@madisonct.org (203) 245-5602
6. Please explain the incident:

   1. Loss
   2. Accident
   3. Notice Only
7. Date and Time of Incident
   Date and Time of Incident

   Date and Time of Incident
8. Location
   Please describe where the incident took place.
10. Name (1)
11. Address (1)
12. Phone (1)
14. Name (2)
15. Address (2)
16. Phone (2)
20. Witness (1) Name
21. Witness (1) Phone
23. Witness (2) Name
24. Witness (2) Phone
26. Description of Incident:
30. Reported by: Name
31. Phone:
33. Address
35. Department
    (if applicable)
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field