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Claim Form

  1. City of Hot Springs Claim Form

    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. Please return all documents to:

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

  3. Claimant Information

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

  5. Incident Information

  6. Do you have insurance which covers your damage in this incident?*

  7. The City will not pay a claim in an amount exceeding a Claimant’s insurance deductible, if covered.

  8. By signing below, I acknowledge that the above-provided information is true and correct to the best of my knowledge and belief.

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

  9. Shaded areas for City Staff only

  10. DEPARTMENT RECOMMENDATION

  11. CITY MANAGER AUTHORIZATION

  12. Leave This Blank:

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