City of Tampa Seal

City of Tampa - Citizen Claim Form

SUBMISSION OF A CLAIM DOES NOT GUARANTEE PAYMENT BY THE CITY

Date and location must be included and accurate to consider your claim

" * " Indicates a Required Field

DESCRIBE PROPERTY DAMAGED (If not applicable, enter N/A)
IF PROPERTY IS YOUR VEHICLE, INCLUDE BELOW INFORMATION
INJURY INFORMATION (If not applicable, enter N/A)
WITNESS INFORMATION
Claim Attachement(s) - Limited to 5 Attachments

The information on this form is confidential information under Florida Statute 768.28.  Any person who knowing and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree (Florida Statute 626.8797).

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