HomeMy WebLinkAboutVjekoslav Bampa - Tort Claim Claim for Property Damage or Bodily Injury
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:
Vjekoslav Bampa
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:*
12/05/24 08:15:00 AM
Location of Incident:*
1216 9th ave e
DESCRIBE IN DETAIL WHAT DAMAGE OR INJURY OCCURRED:
City sewer line backed up and flooded my basement
Additional Files/Pictures:
You may attach any other information or documentation you desire.
Cost of Property Damage or Bodily Injury:*
$16,965.00
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
1/8/2025
"i11O_&Q "OQlfWa
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.