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Claimant Information

Please fill out all information that applies to your claim. You may also add pictures as attachments.
Claimant's First Name*
Claimant's Last Name*
Claimant's Home Address*
City*
State*
Zip*
Phone (Home)*
Phone (Office)
Phone (Cell)
Email *
Claimant's Auto Make
Auto Year
Plate Number
Additional Claimant Name
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Date and Time of Incident*
Date and Time of Incident
Date and Time of Incident
Type of Incident*
Location of Incident*
Nature and Extent of Damage Sustained*
BE SPECIFIC AS TO THE NATURE OF THE INJURY OR DAMAGE.
State in specific detail the circumstances of how and where the incident occured*
Were you admitted to a hospital as a result of this incident?*
If so, what hospital and what were the admission dates and release dates?
Did you incur lost wages?*
If so on what date did you stop working?
If so on what date did you stop working?
What day did you return to work?
What day did you return to work?
How long have you been working for your employer?
Have you filed a claim for compenstation under the Texas Workers' Compensation Law?*
Date of Claim
Date of Claim
Have you recevied benefits?
What is the amount of the benefits you have received?
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First Name
Last Name
Phone Number
First Name
Last Name
Phone Number
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I hereby affirm that the information submitted electronically on this form is true and correct and based on my personal knowledge and I hereby authorize the release to the City of Watauga any and all information with regard to medical history, consultations, prescriptions, diagnosis, reports or treatments, and employment records as the same relates to this claim.
By submitting this claim form and entering your name below you are digitally signing and verifying that the information provided is accurate and belongs to you.
Claimant Digital Signature:*

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