HomeMy WebLinkAboutLiability Claim Form-11-2024CITY OF SOUTH BEND JAMES MUELLER, MAYOR DEPARTMENT OF LAW
SANDRA KENNEDY JENNA K. THROW
CORPORATION COUNSEL CITY ATTORNEY
1200 COUNTY-CITY BUILDING 227 W. JEFFERSON BOULEVARD SOUTH BEND, INDIANA 46601-1830
PHONE 574/235-9241
FAX 574/235-7670
TTY 574/235-5567
REQUIREMENTS FOR FILING A LIABILITY CLAIM WITH THE CITY OF SOUTH BEND
Under Indiana law, a notice of claim against the City must describe in a short and plain statement the facts on which the claim is based, including:
1)Circumstances which brought about the loss;
2)Extent of the loss – please provide two (2) written estimates for property damage;3)Time and place the loss occurred;
4)Names of all persons involved, if known;
5)Amount of the damages sought; and
6)Claimant’s residence at the time of loss and the time of filing the notice.Ind. Code § 34-13-3-10.
If you desire to pursue a claim against the City, please forward the information required by the statute set forth
above. You may use the enclosed form.
Providing this required information to the City does not mean that the City will pay the claim. Instead, this
information must be provided before the City may begin to process the claim.
Pursuant to Ind. Code § 34-13-3-12, the claim must be received via mail or hand delivery to:
City of South Bend
Department of Law Attn: Claims Administrator
1200 County-City Building 227 W. Jefferson Blvd.
South Bend, Indiana 46601
A notice of claim must be filed with the City within 180 days after the loss occurred. Ind. Code § 34-13-3-8.
After a claim is filed, the City has ninety (90) days to approve or deny the claim. Ind. Code § 34-13-3-11. You
will receive a written response from the City once a determination is made. Frequent or repeated contact to the City will not result in the expedited handling of a claim.
DANIELLE WEISS MICHAEL SCHMIDT KYLIE CONNELL THOMAS E. PANOWICZ
JESSICA S. MCLAIN ADAM E. TAYLOR JOHN DORBIN, JR.
2
CITY OF SOUTH BEND
LIABILITY CLAIM FORM
(Please write or print clearly)
Claimant Name: Telephone: ______________________
Address: __________________________________________________________________________________
Number Street City State Zip
Date and Time Loss Occurred: _________________________________________________________________
Location Loss Occurred: _____________________________________________________________________
Extent of Loss: (Please provide two (2) written estimates for property damage): ____________________________
Describe what happened:
Names of Persons Involved (If Known): __________________________________________________________
Amount of Damages Sought: __________________________________________________________________
Claimant’s Residence at Time of Loss: ___________________________________________________________
Signature: ____________________________________________ Date: ______________________________
Please mail or deliver to: City of South Bend Department of Law
Attn: Claims Administrator
1200 County-City Building 227 W. Jefferson Blvd.
South Bend, Indiana 46601