CITY OF SAN ANTONIO

Notice of Claim

NOTICE OF CLAIM

Personal Injury - Property Damage


File this Claim for an injury or property damage with:
City of San Antonio
Office of the City Clerk
P.O. Box 839966
San Antonio, Texas 78283 - 3966
Fax: (210) 207-7032

Contact Information

* First Name:
M.I.:
* Last Name:
* Address:
* City:
* State:
* Zip Code:
* Email:

Please enter a phone number for any of the following that apply

Home:
Cell:
Other:

*Please confirm the accuracy of these statements

By checking this box I, , confirm that the following statements are true and correct to the best of my knowledge on this day of

Claim for injury

In the next section describe in your own words where, when, and how the damage or injury occurred. Attach additional pages if necessary. Give names and addresses of others involved and/or witnesses, if known.

*Location of loss (Please be specific)

* Date of occurrence:
* Time of occurrence:

*Description of how damage or injury occurred
*Attach legible copies of all medical reports, medical bills and/or estimates of damages regarding this loss.

File must be less than 20 MB. Please click the Add Attachment button to add your document(s).

Other information

If known, the TOTAL amount of your claim against the CITY OF SAN ANTONIO is:
POLICE CASE NUMBER (if known):

CITY OF SAN ANTONIO

Notice of Claim

City Charter Section 150 - Liability of the City and Limitations Thereon:

"Before the City shall be liable for damages for the death or personal injuries of any person or for damage to or destruction of property of any kind, the person injured, if living, or his representatives, if dead, or the owner of the property injured or destroyed, shall give the City Manager or the City Clerk notice in writing of such death, injury, or destruction within ninety (90) days after same has been sustained, stating in such written notice when, where, and how the death, injury or destruction occurred, and the apparent extent of such injury, and the amount of damages sustained, provided, however, that in no event shall the City be liable in damages to anyone on account of any defect in, obstruction on, or anything else in connection with any sidewalk in the City, and provided further, that in order to hold the City liable in damages to anyone on account of any injury caused by any defect in, obstruction on, or anything else in connection with any street, alley, or plaza, bridge, riverbank, water course, or any public way, it must be shown that the City Manager, a member of the Council or some person having superintendence or control of the work for the City, had actual knowledge or actual notice of such defect, obstruction or other thing for a sufficient length of time before such injury was received, to have remedied or guarded against such condition of the street, alley or plaza before the injury was received."

NOTE: Once your claim is received, it will be investigated by the appropriate department(s). When their investigation is completed, your claim will be forwarded to our claims service for handling.

Under MMSEA Section 111, any entity that pays settlement, judgment, award or other payment after July 1, 2009 is required to report that claim to Medicare. To meet these mandatory reporting requirements, you will be required to submit your date of birth and social security number before payment is made on your claim. For additional information on MMSEA Section 111, visit: https://go.cms.gov/mirnghp.

Should you have any questions regarding your claim, please contact:

Office of Risk Management/Liability Division
City of San Antonio
P.O. Box 839966
San Antonio, Texas 78283-3966
(210) 207-7204
GR.1000-20-a.Legal.Claim.Notice of Claim
Rev. 3/25/2022

GR.1000-20-a.Legal.Claim.Notice of Claim
Rev. 3/25/2022