A claim may be made against the City for some types of property damages or personal injuries. This claim against the City is also known as a tort claim, which is enacted by the Kansas Tort Claims Act, K.S.A. 12-105-b.

The claim against the City requires a written notice with the City Clerk or the Governing Body and should contain the following:

1. Name and address of the claimant and the name and address of the claimant's attorney, if any;
2. A concise statement of the factual basis of the claim, including the date, time, place and circumstances of the act, omission or event complained of;
3. The name and address of any public officer or employee involved, if known;
4. A concise statement of the nature and extent of the injury claimed to have been suffered; and
5. A statement of the amount of monetary damages that is being requested.

A claimant may not take legal action within 120 days after filing the notice of claim, unless the City denies the claim and provides notice before the 120 days expire.

The City Clerk's Office will coordinate the tort claims with the City's risk manager.

1

Claimant Information

 *

Claimant Information

First Name:	Last Name:	Street Address:
City:	State:(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip:
Primary Phone:ext.	Alternate Phone:ext.	Email:

2

 Claim Information

 *

Claim Information

Incident Date:

Incident Time: (Indicate a.m. or p.m.)

Incident Location:

Describe what happened:

3

What is damaged?

 *

What is damaged?

Auto

Other If other, type text here.

4

What is the type of damage?

 *

What is the type of damage?

Property Damage

Bodily Injury

Other

5

What is the extent of damage?

 *

What is the extent of damage?

6

Were City officials or employees involved?

 *

Were City officials or employees involved?

Yes

No

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