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General Liability Claim Form
City of Charlotte, Mecklenburg County, Charlotte-Mecklenburg Board of Education
 
Name
First
MI
Last
 
Address
Street
City
State
Zip
 
Phone
Day
Home
 
Incident Information
Incident Date
Time of Day
AM
PM
Weather Conditions
 
Tell us what happened:
 
Was Anyone Injured? If so, give names and describe injury:
 
Property Damage/Type:
 
Estimate Damage Amount:
 
Responsible Party?
City
County
School System
 
Have you been in contact with the responsible department?
Yes
No
 
If so, name of person:
 
City of Charlotte