Form Center

2. 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.

4. Name of Claimant*
6. Address*
8. City*
9. State
10. Zip Code
12. Phone Number*
13. Email Address*
15. Date and time of incident*
16. Location of accident or loss (be specific)*
18. Describe the accident or occurrence which caused injury or damage.*

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

20. What were weather conditions at the time of the incident?*
22. Please provide the name, address and phone number of any witnesses:
24. Did Police investigate the incident?

    If so, please provide police report number.

26. Was anyone injured?

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

28. Please include quotes, estimates, photos that are applicable:
30. Upload photo/file:
31. Upload photo/file:
32. Upload photo/file:
34. Was any damage done to property?

    If so, please describe property and extent of damages.

36. What other damages do you claim, if any?
38. Have you been compensated for part or all of your claim by any insurance company?

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

40. What amount do you claim in damages?*
42. Have you made any claim against anyone else for damages as a result of this incident?

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

44. 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.

    1. I agree.
46. Electronic Signature*
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field