Notice of Claim Form

THIS NOTICE MUST BE PRESENTED TO THE CITY OF BEAUMONT WITHIN SIX (6) MONTHS AFTER THE INCIDENT OCCURS BEFORE THE CLAIM SHALL BE CONSIDERED.

First and Last Name
Include area code
Address
Address
City
State/Province
Zip/Postal
0 of 10000 max characters
(State in detail where, when, and how the accident occurred and the extent of any injuries or damages)
If no witnesses, enter “NONE” in box above
By signing, I certify that all of the information submitted on this form is true and accurate.
If no witnesses, enter “NONE” in box above
If no witnesses, enter “NONE” in box above
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