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Ankeny Claim Form

  1. This is a filing of a claim against City of Ankeny, 410 W First St., Ankeny, Iowa. Please complete this form in full, this report constitutes your claim against the City of Ankeny. You are advised that no representations made by you to any employee or City of Ankeny, Iowa can in any way waive any of the requirements of law as to the report of your claim. You are further advised that failure to file this report within sixty days of the date of the incident may invalidate your claim against the City of Ankeny.

  2. Please give full details upon which you have your claim. If an employee was involved, please provide their name.

  3. If so, please provide police report number.

  4. If so, please provide names, address, phone number and extent of injuries.

  5. Please include quotes, estimates, photos that are applicable:
  6. If so, please describe property and extent of damages.

  7. If so, please provide the name, address, phone number and amount paid.

  8. If so, please also include if you have received any payment and what amount.

  9. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

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  11. This field is not part of the form submission.