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 Vehicle

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

Report Date

Claimant

Claimant Email

Claimant Information

Claimant Address1

Claimant Address2

Claimant City

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Claimant Postal

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Claimant Home/Mobile Phone

Incident Details

Loss Date

Event Description

Loss Description

Alleged Damages

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Specify Other Property

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Please explain cause

Weather Condition Value is not selected

Road Conditions Value is not selected

Was a Police Report Taken?

Yes

No

Police Agency

Police Event/Incident Number

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Witnesses

Location Details

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Event Location

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Cross Street 1

Cross Street 2

Accident City

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Accident Postal

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Claimant Vehicle Information

VIN

Vehicle Make

Vehicle Model

Vehicle Year

Vehicle Tag

Claimant Vehicle Driver

Driver's Name

Driver's State Value is not selected

Driver's License Number

Vehicle Registered Owner Information

Registered Owner Name

Insurance Carrier

Registered Owner Phone Number

Policy Number

Registered Owner Address1

Registered Owner Address2

Registered Owner City

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Registered Owner Postal Code

City of North Las Vegas Driver and Auto Details

Employee Driver Value is not selected

Clear

Vehicle

File Attachments

Supporting Documents

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Finance - RM Damaged Non-Company Vehicle