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2. Type of Incident *

   1. Pothole
   2. Other Roadway Obstruction
4. Description of the "Other Roadway Obstruction", if applicable
6. Vehicle speed when the incident occurred*
8. Your Contact Information
10. First Name*
12. Last Name*
14. Address Line 1*
16. Address Line 2
18. City/Town*
20. State*
22. Zip Code*
24. Phone Number*
26. Email Address*
28. Information about the incident
30. Location of Incident*
32. Date of Incident (mm/dd/yyyy)*
34. Approximate Time*
36. Vehicle Information
38. Vehicle Year*
40. Vehicle Make*
42. Vehicle Model*
44. Registration Number*
46. State of Vehicle Registration*
48. Are you the Vehicle Owner

    1. Yes
    2. No
50. Registration Type

    1. Commercial
    2. Passanger
    3. Motorcycle
    4. Other
52. Was this incident reported to the Town when it Occured? *

    1. Yes
    2. No
54. If the incident was reported to the Town, when (mm/dd/yyy)
56. Which department(s) was the incident reported to?
58. Name of employee(s) you spoke to about this incident?*
60. Explain the cause of the incident (please be as specific as possible)*
62. Description of Damages (please be as specific as possible)*
64. Estimated Repair Cost (provide source of estimate)*
66. Supporting Document #1
68. Supporting Document #2
70. Supporting Document #3
72. Supporting Document #4
74. Supporting Document #5
76. Did you notify your insurance company?*

    1. Yes
    2. No
78. Name of Insurance Company
80. Other Information Regarding the Incident
Leave This Blank:


82. 1. Receive an email copy of this form.
83. Email address

    This field is not part of the form submission.

84. Submit Submit and Print

* indicates a required field