Form Center

2. Because the City of Roanoke is a Municipality, the State of Virginia § code15.2-209 states that: "Every claim cognizable against any county, city or town for negligence shall be forever barred unless the claimant or his agent, attorney, or representative has filed a written statement of the nature of the claim." In submitting your claim, include the following information:
4. Name*
   Your Name, Address, and a Phone Number where we can reach you.
6. Address*
8. City*
9. State*
10. Zip Code*
12. Phone Number*
13. Email Address
15. What Happened?*
    Give as many details as possible in the words of the claimant.
17. When did the incident take place?*
    State the exact date of the occurrence and an approximate time.
18. Where did the incident take place?*
    State the exact location of the incident: physical address, street names, mile markers, landmarks.
20. Uploads
    To aid in sustaining your claim you may provide photos of the exact location and surrounding areas so that the area can be easily identified by using the following links.
22. Upload 1
23. Upload 2
24. Upload 3
25. Upload 4
27. Upload 5
28. Upload 6
29. Upload 7
30. Upload 8
32. Statement*
    Provide a statement asking that the City of Roanoke pay for damages.
33. Have you contacted your insurance?

    1. Yes
    2. No

    Check one. If Yes, then your insurance provider must file this claim on your behalf. If No, then proceed with filing your claim here.
35. Repair Estimates or Receipts
    Provide repair estimates and/or receipts on a company's letter.
36. Accident or Police Report
    Provide a copy of the Accident or Police Report if available.
38. The claimant has six (6) months from the date of the incident to file the claim against the City of Roanoke. Make sure that all of your above information is correct and complete.
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit Submit and Print

* indicates a required field