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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Email Address*
14. Date of Incident*
    Date of Incident

    Date of Incident
15. Accident or Police Report (if available)

    Provide a copy of the Accident or Police Report if Available

17. Location of Incident (Address)*

    Where did it happen?

19. City*
20. State*
21. Zip Code*
23. Describe the Specific Damage and/or Injury*

    What was damaged or injured?

25. Explain the Circumstances that Led to the Damage or Injury*

    How did the damage or injury happen?

29. File Uploads

    Providing photos or supporting documents of your claim will aid in determining the compensability of your claim.

    *Please note: If you have more photos/files than the amount able to be uploaded below, email the remaining documents to riskmgmt@charlottesville.gov with your last name and street name in the subject line.

31. Upload 1
32. Upload 2
33. Upload 3
34. Upload 4
36. Upload 5
37. Upload 6
38. Upload 7
39. Upload 8
43. Vehicle Accident Claims

    Please fill out your vehicle information below if your vehicle was involved in an accident with a City of Charlottesville vehicle.

45. Year of Vehicle
46. Vehicle Make
47. Vehicle Model
48. License Plate Number
50. Driver First & Last Name (if other)
51. Driver Email Address (if other)
53. Driver Address (if other)
55. City (if other)
56. State (if other)
57. Zip Code (if other)
59. Driver Phone Number (if other)
60. City of Charlottesville Vehicle Information (if available)
62. Damage Repair Estimates or Receipts
63. Have you contacted your insurance?

    1. Yes
    2. No
67. Person(s) Injured

    Fill out the information below if you and/or others were injured. If multiple people were injured, please email riskmgmt@charlottesville.gov 

69. First and Last Name
70. Email Address
72. Address
74. City
75. State
76. Zip Code
78. Phone Number
79. Injury Sustained
Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit Submit and Print

* indicates a required field