To file an insurance claim with the City of Germantown, fill out the following:

Claim Form    and    Accident Questionnaire

Click HERE to download a fillable PDF of both claim and accident forms.

All applicable sections must be fully filled out on the claim form and accident questionnaire or the claim will be incomplete.  Please provide the following:

• Provide the exact date and approximate time of the alleged incident.
• If applicable, provide the street address where the alleged damage or injury occurred.
• Provide the name of the City department that allegedly caused the damage or injury, if known.
• Provide the full name, mailing address, email address and telephone number of the person(s) claiming the damage or injury.
  • Note: All correspondence will be sent to the person(s) listed unless a representative's name is provided. If the claim is being filed on behalf of a minor, specify your relationship to the minor, and the date of birth of the minor. Also, if medical expenses are claimed, you must provide your date of birth and Social Security Number so we can comply with the mandatory Medicare insurer reporting requirements that may be applicable. 
• Describe the incident in full detail.
• Describe in full detail the facts surrounding the incident that support your claim. State all facts that support your claim and why you believe the City of Germantown is responsible.
• State the total dollar amount being claimed as a result of the alleged damage or injury. If damage or injury is continued or anticipated in the future, indicate with a "+" following the dollar amount. Include paid receipts and cost estimates.
• The Claim Form must be signed by the claimant or authorized representative. The City will not accept the claim without a signature and date of signature.
• Both the Claim Form and Accident Questionnaire Form must be completed and submitted. 

All claims submitted to the City will be investigated. Submission of a claim does not constitute acceptance of liability by the City.

Forms and supporting documents must be submitted to:

City of Germantown
Attention: Procurement / Risk
1930 S. Germantown Road                                                                                           
Germantown, TN 38138 
Or via email to Risk@Germantown-TN.gov

Important Information For Filing Pothole Damage Claims