CLAIM FOR DAMAGES FORM
(FOR PERSONAL INJURY OR PROPERTY DAMAGE)


Please submit this form with all supporting documents. Please keep a hard copy of your completed claim form and all attachments for your records.

You are required to provide all documentation to support your claim. Failure to provide complete information and/or supporting documents may delay the investigation of your claim.

The Claims Unit will open an investigation into this matter and a Legal Investigator will contact you. In order to check the status of this claim, please contact the Claims Unit at 816-513-3126 to speak with the Investigator or send an e-mail to claimsunit@kcmo.org.


Claimant Information

Name (injured or damaged party) *

If business, name of contact person

Phone *

Email

Address *

City *

State *

Zip *

Property Owner Information (if different from above)

Name

Relationship to claimant

Phone

Address

City

State

Zip

 

Incident Information

When did the injury or damage occur? (date and time) If the injury or damage occurred over a period of time, date of first and last occurance
(limit 3000 characters)

Where did the injury or damage occur? (location name, street address, intersecting streets, etc.) *
(limit 3000 characters)

How did the injury or damage occur? (attach additional information, if necessary)
(limit 3000 characters)

Describe the injury or damage claimed? (provide full details; attach any supporting documentation, e.g., photos, receipts, medical records)
(limit 3000 characters)

If the claim relates to personal injury and you are currently receiving Medicare or Medicaid, please provide your Medicare or Medicaid number.

Police report number (if applicable)

Claim category *

Vehicle Information (if the claim relates to damage to a motor vehicle, please answer the following)

Make and model

Year and color

Name on title

Current location of vehicle

Insurance company

Policy number

  Please check this box if there was no insurance coverage in effect at the time of the incident

Witness Information Name of any witnesses, doctors, hospitals, etc. (attach additional documentation, if necessary)

First Witness

Name

Phone

Address

City

State

Zip

Second Witness

Name

Phone

Address

City

State

Zip

Attach Documents

Attach your supported documents one at a time. Click on "Browse or Choose File", select the file in the new window and click on "Attach". Repeat this for each document you want to attach. Please make sure that all attachments are legible and not in a secured format.

Only files in the following formats will be allowed: pdf, jpg, png, and gif. All files cannot exceed 28 MB.

All files size   0



Claimant Certification

   * I certify under penalty of perjury that, to the best of my knowledge and belief, all of the information on and attached to this form is true, correct, complete and made in good faith.