Online Tort Claim Submission Form

Claimant Information

Enter the information for the person making the claim.

Claimant Last Name   Enter the last name of the person making the claim.

Claimant First Name   Enter the first name of the person making the claim.

Claimant Date of Birth Select the date of birth for the person making the claim.

Claimant Business (if applicable) If this claim is for a business enter the business name.

Mailing Address   Enter the street and number, or PO Box of the mailing address for the claimant.

City Enter the city of the mailing address for the claimant.

State   Enter the state of the mailing address for the claimant.

ZIP Code   Enter the zip code of the mailing address for the claimant.

Claimant Phone Number   Enter the phone number for the claimant. Include area code (e.g. 505-555-5555).

Claimant Email Address   Enter the email address for the claimant.

Contact Information

Only fill out this section if different from claimant i.e.attorney represented, insurance company.

Contact Last Name Provide contacts last name.

Contact First Name Provide contacts first name.

Contact Business (If applicable) Enter the name of the contact's business.

Your Claim Number (if applicable) Enter the claim number from this incident.

Contact Mailing Address Enter the street and number or PO box of the mailing address for the contact.

Contact City Enter the city of the mailing address for the contact.

Contact State Enter the state of the mailing address for the contact.

Contact ZIP Code Enter the zip code of the mailing address for the contact.

Contact Telephone Enter the phone number for the contact. Include area code (e.g. 505-555-5555).

Contact E-Mail Address Enter the email address for the contact.

Incident Information

Describe how the incident occurred and why you feel the City of Albuquerque is at fault  

Describe Injury or Property Damaged  

If Property Damage is a Vehicle If the property damaged was a vehicle enter the year, make, and model below.

Vehicle Year Enter the manufactured year of the damaged vehicle.

Vehicle Make Enter the make of the damaged vehicle.

Vehicle Model Enter the model of the damaged vehicle.

Vehicle Licence Plate Enter the license plate number of the damaged vehicle.

Did Police Investigate?  

Yes
No

Police Report (Agency and Number)

Did the loss involve a City of Albuquerque Vehicle?  

Yes
No

If loss involved a City of Albuquerque vehicle:

City Vehicle License Plate

City Vehicle ID#

City Vehicle Description Describe the type of City vehicle involved in the incident.

Name of City Driver