[City of Gastonia] General Liability Claim Form

General Liability Claim Form

You will be contacted in 24-48 hours regarding your claim

Phone Number

Location of Incident (include street number, landmarks, or nearest intersection)

Date and Time of Incident

Tell us what happened

Was anyone injured?

Yes

Describe Injuries

Vehicle Damage?

Yes

Describe your vehicle: Year, Make, Model

Describe Vehicle Damage

Property Damage?

Yes

Describe Property Damage

Are you the property owner?

Yes

Witness Name / Phone # (if applicable)

Police Report Number (if available)

Upload estimate, invoice, and/or photos

Click Here to Upload

Please provide Name and Phone Number of any other person or department with whom you have been in contact.

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