HomeMy WebLinkAboutAnthony Zahrn - Tort Claim Claim for Property Damage or Bodily Injury
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NOTE:This form is being provided as a courtesy to assist you in filing your claim.Providing this form to you is not an admission,nor shall it be
construed to be an admission,of liability or an acknowledgement of the validity of a claim by the political subdivision.Legal requirements for
filing claims can be found in Idaho Code:Title 6.Chapter 9.All claims must be filed promptly.
CLAIMANT INFORMATION:
First Name:* Last Name:
Anthony Zahrn
Physical Address
Street*
City* State* ZIP Code*
Twin Falls Idaho 83301
Have you lived at this address for at least 6 months prior to the incident date?
Yes No
My mailing address is different than my physical address
Phone Number* Email Address:
xxx-xxx-xxxx
INCIDENT INFORMATION:
.....................................................................................................................................................................................................................................................................................................................................................................................................................................
Date of Incident:*
02/11/25 12:32:00 PM
Location of Incident:*
Construction Zone North of the Eastland Drive,Addison Avenue Intersection.
DESCRIBE IN DETAIL WHAT DAMAGE OR INJURY OCCURRED:*
While driving through the construction zone on Eastland Southbound to O'leary Middle School before the Addison Ave Intersection.The
broken concrete section caused damage to our driver side rear tire in the sidewall making it unfixable.The sidewall of the tire has been
dented punctured and cracked.
Additional Files/Pictures:
Point S Invoice.jpg 3.48MB
tire 4.jpg 2.99MB
tire 1.jpg 3.49MB
tire 2.jpg 2.35MB
tire 3.jpg 2.94MB
You may attach any other information or documentation you desire.
Cost of Property Damage or Bodily Injury:
$142.08
Property Damage or Bodily Injury:*
Property Damage
Bodily Injury
Property Damage and Bodily Injury
I hereby make a claim against the City of Twin Falls and I hereby certify that I have read the above information and it is true and correct to the
best of my knowledge.
Date* Signature*
2/12/2025
&ortlrow/Zakto
Per Idaho Statute Title 41,Chapter 13:41-1331 -Any person who knowingly,and with intent to defraud or deceive any insurance company,files a
statement of claim containing any false,incomplete,or misleading information is guilty of a felony."Statement'includes,but is not limited to,
any notice,statement,proof of loss,bill of lading,receipt for payment,invoice,account,estimate of property damages,bills for services,
diagnosis,prescription,hospital or doctor records,x-ray test results,or other evidence of loss,injury,or expense.