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If you believe you or your property have obtained injury or damage that the City is liable for, please fill out the appropriate Liability Claim form located below.  Please be sure to include all information requested in the form and be as detailed as possible.

What to expect during the Liability Claim Processing

  1. Claimant submits form via website
  2. City finance Department sends claim form into City’s Insurance Carrier
  3. Insurance Carrier reviews claims and sends letter to City on Approval or denial decision
  4. City Council reviews and approves decision from Insurance Carrier
  5. Claimant receives a letter from City Clerk’s office informing them on the status of their claim.

**Note this Process could take up to six weeks**

Claim Forms

City of Kaukauna Personal Injury Liability Claim Form

TIME & PLACE

mm/dd/yyyy
Address
City
State/Province
Zip/Postal

DESCRIPTION OF ACCIDENT

WITNESSES

Leave blank if there is no witnesses present at time of Acident
Address
City
State/Province
Zip/Postal
plus1 Add minus1 Remove

INJURED PERSON AND INJURIES

Address
City
State/Province
Zip/Postal
Address
City
State/Province
Zip/Postal

Property Damage

If property was damage as a result from the above incident please fill in this section.
Sending
City of Kaukauna Property Damage Claim Form

DAMAGE TO PROPERTY

Address
City
State/Province
Zip/Postal
Sending

If you believe you’ve been involved in an incident with a city owned vehicle while traveling on the road please submit the below form. Please ensure to indicate what police department drafted the incident report.  Be as descriptive as possible when explaining what you believe happened to cause the incident you are reporting.

City of Kaukauna Accident Reporting Form
Home Address of Driver
City
State/Province
Zip/Postal

Witness Info

Address
City
State/Province
Zip/Postal
plus1 Add minus1 Remove
Sending
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