Finance - RM Auto Incident With Bodily Injury (Non-Employee)

City of North Las Vegas
Risk Management Division
2250 Las Vegas Blvd., North, Ste 820
North Las Vegas, Nevada 89030

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AUTO INCIDENT WITH BODILY INJURY REPORT (NON-EMPLOYEE)

Contact Information
Risk Office: (702) 633-1417
Fax: (702) 399-8426
riskmanagement@cityofnorthlasvegas.com
 

 

 

Claimant Information

Driver and Auto Details

Incident Details

Was there a police report?
Were there witnesses?

File Attachments

Related to bodily injury cases. Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA Section 111) information: Under MMSEA Section 111, any entity that pays settlement, judgment, award or other payment after July 1, 2009 is required to report that claim to Medicare. To meet these mandatory reporting requirements, you will be required to submit your date of birth and social security number before payment is made on your claim. For additional information on MMSEA Section 111, visit: www.cms.hhs.gov.mandatoryinsrep.