Liability Claim Form

To submit a claim to the City of Champaign, please provide the following information. Any claim submitted has to be investigated. You will be contacted to let you know if your claim has been accepted.
Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Email
Date of the Incident*
If you do not know the exact date of the incident, please pick the date closest to the incident.
MM slash DD slash YYYY
Location of Incident*
Please be as specific as possible, giving information such as eastbound, southbound, lane nearest curb, etc.
Description of Incident*
Please provide as much information as possible.
Nature of Injury or Property Damage*
Year, Make, and Model of Vehicle (If a personal vehicle is involved)
Was a City of Champaign vehicle involved?
- Yes
- No
If yes, what is the vehicle number and/or driver's name?
Have you spoken with or reported this incident to anyone at the City of Champaign?
- Yes
- No
If yes, what is the person's name, position, and phone number?
*Indicates a required field
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Human Resources Department