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

Incident Information
Damage Non-Company Property

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

Property Owner's 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:

Property Owner's Name

Email

Address1

Home/Cell Phone

Address2

City

State Value is not selected

Postal Code

Event Details

Location where occurred

Time and Date Occurred

Detailed statement of facts concerning what happened:

Date Property/Item Purchased

Description of Property/Item Purchased

Character and extent of injury or damage

Did you file a police report?

Yes

No

Police Information

Police Agency

Police Event/Incident Number

Were there Witnesses?

Yes

No

Witnesses

Other Information and Agreement

Estimated Cost of Damage

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.) *

Signature Box

Signature Date

File Attachments

Attach Supporting Documents

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Finance - RM Damaged Non-Company Property

Property Owner's Information