Notice Of Tort Claim Form (Page 2 of 2) in pdf

B. THIS SECTION IS FOR USE BY THE PUBLIC ENTITY WHICH

To inquire about this claim you may write to

RECEIVES THE CLAIM

OMAG Claims Dept. or call 1-800-234-9461

This Notice of Tort Claim was received by _________________________________________________________________

(Title) _____________________________________________, on ____________________________________, 20______

For further information on this claim contact _______________________________________________________________

(Title) ___________________________________________, by telephone at (

)

The following reports, statements or other documentation, which support our understanding of the facts relating to this claim

are attached:

____________________________________________________________________________________________________

Information for City Owned Vehicle Involved:

Year: _________ Make: _______________ Model: _______________ Last 4 Vin#:____________ Dept:_______________

As a result of this incident, are there damages to the City vehicle? ____YES ____NO

If YES, please fill out an

OMAG Auto Loss Notice

to have it repaired.

Persons who have knowledge of the circumstances surrounding this claim are:

Name

Title/Position

Telephone

1._____________________________________

__________________________

____________________

2._____________________________________

__________________________

____________________

3._____________________________________

__________________________

____________________

4._____________________________________

__________________________

____________________

Submitted by: __________________________________________Date___________________________, 20___________

Title: ________________________________________________

AFTER THE PUBLIC ENTITY HAS RECEIVED THIS

CLAIM, PLEASE PROVIDE INFORMATION REQUESTED

ABOVE AND IMMEDIATELY SEND TO:

OMAG Claims Dept.

3650 S. Boulevard

Edmond, OK 73013

Phone (405) 657-1400

Fax (405) 657-1401

Notice Of Tort Claim Form Page 2