Protester Property Claim Form
CLAIMS PROCEDURE
This is an explanation of the claims procedures and a claim form for you to complete and return
if you wish to file a claim.
1. Complete the attached claim form, including all details related to the alleged
incident. You may use additional stationery to explain in greater detail, if
necessary.
2. If property damage is claimed, please provide a picture along with two (2)
estimates from reputable business firms that perform such repair work. If
personal injury is claimed, please submit copies of all incurred medical expenses
to date.
3. If reimbursement of towing/storage charges is claimed due to the theft of a
vehicle, please provide a copy of the insurance policy that lists the type of
coverage, or a letter from the insurance company to verify policy information, and
a copy of the Stolen Vehicle Report taken by a law enforcement agency.
4. Please list a phone number where you can be reached Monday through Friday
between the hours of 8:30 – 4:30 p.m., in case additional information is needed
to process your claim.
After the necessary information is received, an investigation of the claim will be undertaken. In
most cases, within four weeks of receipt of your claim, you will be notified of the results of our
investigation. Please return the attached claim form to:
Metro Risk Management Division
Attn: Claims Processing Assistant
611 West Jefferson Street
Louisville, KY 40202
(502) 574-3404 Fax: (502) 574-3932
Email: RiskMgmtDivision@louisvilleky.gov
The Louisville/Jefferson County Metro Government reserves the right to deny any claim based
on its facts and any applicable law.
CLAIM FORM For Office Use Only
Metro Call#:
RETURN TO: METRO RISK MANAGEMENT DIVISION _________________
ATTN: CLAIMS PROCESSING ASSISTANT
611 WEST JEFFERSON STREET Claim#:
LOUISVILLE, KY 40202 _________________
Phone: (502) 574-3404 Fax: (502) 574-3932
Email: RiskMgmtDivision@louisvilleky.gov
CLAIMANTS NAME: ___________________________________________________________________________
ADDRESS: ___________________________________________________________________________________
(STREET) (CITY/STATE) (ZIP)
TELEPHONE NUMBER YOU CAN BE REACHED AT BETWEEN 8:30 – 4:30 _____________________________
DATE AND TIME OF ACCIDENT/ INCIDENT/ TOW-IN: ________________________________________________
LOCATION WHERE INCIDENT OCCURRED: ____________________________________________________
_____________________________________________________________________________________________
Note: For road or sidewalk related claims; if possible, please submit a photograph of the area where the
incident occurred or be as specific as possible. Include the direction of travel, nearest intersection, abutting
street number or building description, so we may investigate the specific location.
DESCRIPTION OF INCIDENT: _________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
AMOUNT OF CLAIM: ____________________
WITNESSES:
1) Name: 2) Name:
Address: Address:
Phone: Phone:
IF AUTO CLAIM, COMPLETE BELOW:
Make and Model of Vehicle Damaged Other Vehicle Involved
License Plate Number: Driver:
Serial/Identification Number: License Plate Number:
Police Report (Local Code) Number: Vehicle Description (Make & Model/Id Number):
________________________________________________ _____________________________________
CLAIMANTS SIGNATURE DATE
