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Claim Form

  1. Instructions: Complete this form clearly stating the reason for the claim, amount you are claiming, all contact information, and attach appropriate documentation including receipts, estimates, photos, etc. Substantive documentation (written estimates and/or receipts, proof of incident, etc.) MUST be provided to establish all monetary values. Additional sheets may be added. Failure to provide all information and fully substantiate your claim will result in the claim being rejected. Filing a claim does not imply approval; claims will be investigated before a decision is rendered. Claims containing inaccurate or fraudulent information will be rejected.

  2. City of Hot Springs Attention: Claims
    Dorethea Yates
    517 Airport Road Suite C
    Hot Springs, AR 71902

  3. (Please print clearly)

  4. (Last Name, First name, Middle Initial)

  5. The City of Hot Springs requires that you certify your Claim Form by submitting an electronic signature. Type your name and click Confirm Signature.

  6. Leave This Blank:

  7. This field is not part of the form submission.