Claim Form

7555 FM 762
Richmond, TX 77469

First Name Last Name

Phone Number (Business)

Phone Number (Home)

Address1

Address 2

City

State

Zip

The total amount of your claim is:

Describe in your own words where, when, and how the damage or injury occurred. Attach additional pages if necessary. Give names and addresses of any others involved.

First Name Last Name

Location:

Date

Time

How

Give the details of your claim. Attach copies of any pictures, bills, estimates, medical reports, etc.

Witness (es): Name, address, phone number, and relationship to claimant.

All of the statements made in this claim are true and correct to the best of my knowledge and I am aware there are civil and criminal penalties for presenting fraudulent claims:

Date

Signature of Claimant

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