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

GENERAL LIABILITY INJURY (NON-EMPLOYEE)

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

Person Involved Information

COMPLETION OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY, OR ACCEPTANCE OF A CLAIM

Please take notice that a claim is hereby made against the City of North Las Vegas, Nevada, for damages described as follows:

Today's Date

Name of Person Involved

Gender Value is not selected

Address 1

Address 2

City

State Value is not selected

Postal

Email

Home or Cell Phone

Was the Person Involve a Minor? Value is not selected

Injury Details

Nature Value is not selected

Event Details

Location where occurred

Brief statement of facts concerning what happened

Time and Date Occurred

Emergency Information, if any

Was there a police report?

Yes

No

Did Fire or Paramedics Respond?

Yes

No

Policy Agency

Police Event/Incident Number

Character and extent of injury or damage

Was First-Aid or Medical Treatment Provided? Value is not selected

Where there any witnesses? Value is not selected

Injury Depiction

Side of the body

Anterior (Front Side)

Posterior (Back Side)

Not Reportable

Body Area Value is not selected

Body Part Location Value is not selected

Body Part Specify the body part (e.g. forefinger, lumbar, teeth)

Other Information and Agreement

Account of Claim, if known

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

I Certify Checkbox (By checking this box, I HEREBY CERTIFY that the above and foregoing claim against the City of North Las Vegas, Nevada is just and reasonable, and that the claim is now due, owing and unpaid. I DECLARE UNDER PENALTY OF PERJURY that the foregoing is true and correct.) *

By typing your full legal and today's date below to submit this document, you are submitting an official document to the City of North Las Vegas

Signature Box

Signature Date

File Attachments

Please attach any files, reports, pictures, statements, and/or estimates related to the incident below, thanks.

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Finance - RM GL Non-Employee Injury Claim