Claimant's Name
*
Claimant's Address
*
Email Address
*
Day Phone
Evening Phone
Date of Birth
Social Security Number
Month
Day
Year
Time
a.m. or p.m.
At which location did the damage or injury occur?
Police Report No.
What happened and why is LPFD responsible?
Name and position of responsible LPFD Employee(s), if known
What damage or injury occurred?
Claim Amount
How did you arrive at the amount claimed?
Declaration date
Declaration year
Declaration City
Signature of Claimant or Representative
Name and Capacity
Address
City, State, Zip
Day Phone
Evening Phone
Please verify that you are human
*
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