Contact Information

Contact Information

City Clerk's Office

952-563-8729
Title

City of Bloomington Claim Form

Sections
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City of Bloomington Claim Form

  • Overview
  • Claimant's info
  • Incident/accident info
  • Documents
  • Signature and submission
  • Complete

Instructions

  1. Per MN Statute 466.05, the claim must be filed with the City Clerk office within 180 days of the occurrence.
  2. The claim must be based on the fault or liability of the City or its employees. The City may deny any claim where the City is not at fault.
  3. Please complete this form in its entirety by typingyour answer to each question in the space provided. If additional space is needed, please attach additional documents.
  4. Attach copies of bills, estimates, pictures, or other documents outlining the basis for the claim to this form. 

Investigation

  1. Once received by the City Clerk, a copy of this form will be sent to Risk & Litigation Management for processing.
  2. You will generally receive an acknowledgment of your claim within 14 days. You may request additional information at that time.
  3. Claims investigators will research your claim and recommend payment or denial.
  4. If you don’t hear from an investigator within 14 days of your claim submission, or you have questions regarding the progress of your claim, call the City’s Risk and Litigation Manager at 952-563-4932.

Please take notice that any data received by the City as the result of submitting this form will be classified as government data pursuant to the Minnesota Government Data Practices Act, Minnesota Statutes Chapter 13. Under the Data Practices Act, some or all of this data is classified as public data, including your name, address, email address, phone number, and other personal information provided by you. Public data is available to anyone requesting it and consists of all data furnished via this Web form. Please be advised that the correspondence will be added to the public record. The purpose and intended use of the information collected through this form is to obtain public input and data in support of City activities and services. You have the right to refuse to submit this form. If you choose not to submit this form, you will need to contact the City by another means if you wish to provide the information collected by the form.

The City of Bloomington does not discriminate against or deny the benefits of its services, programs, or activities to a qualified person because of a disability. To make a request for a reasonable accommodation, ask for more information, or to file a complaint, contact the Community Outreach and Engagement Division, City of Bloomington, 1800 West Old Shakopee Road, Bloomington, MN 55431- 3027; 952-563-8733, MN Relay 711.