City of Worcester Claim Application

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The liability of the city is set and limited by state law. Generally, the city is liable only for specific acts of negligence in responding to dangerous conditions, not for the dangerous conditions themselves. For example, the city is liable if it does not repair a pothole within a reasonable time after discovering it - the city is not responsible for keeping the streets free of potholes. The law also imposes strict requirements for filing claims. Claims involving streets (potholes, etc) must be filed within 30 days of the incident. If you believe you meet the legal criteria for a claim against the city, you should file a claim against the city.

WHEN TO FILE: If your claim is based on a defect in a public way, you must file within 30 days of the incident. If your claim is based on the negligence or wrongful act or omission of the City or its employees, you must file within two years of the incident.

Submit this form electronically upon completion or print it out and return to: City Clerk, City Hall Room 206, 455 Main Street, Worcester, MA 01608.

For further advice as to the procedure for filing your claim, you should consult a private attorney. NOTE: In the event your claim is denied by the City of Worcester, you have the right to request a hearing before the Claims Committee. You must request this hearing in writing to the Law Department, City Hall Room 301, 455 Main Street, Worcester, MA 01608, and you must be prepared to appear in person on the date that the hearing is scheduled. To request a Claims Committee Hearing, contact claims@worcesterma.gov

Is this claim related to a prior claim?

Yes No

Prior Claim ID

Claimant's First Name:

Claimant's Last Name

Claimant's complete address:

Street Address

Street Address Line 2 (optional)

City

State

Zip Code

Nature of claim:

Auto accident, slip and fall on public way or property damage, etc.

Date and time of incident:

Location of the Incident:

Please select whether the incident occurred at or outside a specific street address or at an intersection.

Street Number

Provide the street address (number and street name) where the incident occurred.

Street Name

Intersection of Incident:

Provide the names of the cross-streets where the incident occurred.

Location Details:

Please include as much detail as possible about the location.

Vehicle:

Are you the registered owner of the vehicle?

Yes No

Registered Owner Name

Year

Make

Model

Vehicle Mileage:

Circumstances of the incident:

Have you submitted a claim to any insurance company for damages arising from this incident?

Yes

Insurance Company

Insurance Claim Number

Optional Upload File(s)

File attachments associated with the ticket.

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Amount of damages claimed:

Be sure to attach any bills incurred or any written estimates of repair or replacement costs. (Any documents that you provide will become the property of the City of Worcester. Therefore, it is suggested you keep copies of any such documents for your files.) Attach any other information you believe will be helpful in the processing of your claim (for example, names and addresses of any witnesses, written medical records if personal injury was sustained).

I certify under the pains and penalties of perjury that the foregoing information is true and correct.

Electronic Signature Agreement

I certify that I agree to use an electronic signature.

Other Fields

Your name

Your email address

Your phone number