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2. Proper notice must be received by the Town within 30 days from the date of the incident.
4. 
   
6. Vehicle Damage Due to Pothole or Other Roadway Obstruction
8. 
   
10. This incident was related to:*

    1. Pothole
    2. Other Roadway Obstruction
12. 
    
14. Description of the “Other Roadway Obstruction”, if applicable.
16. 
    
18. Vehicle speed when the incident occurred?*
20. 
    
22. Incident Date*
24. Approximate Time
    
26. AM/PM
    -- Select One --AMPM
28. 
    
30. Location of the Incident
32. 
    
34. Please be as specific as possible, i.e, street name, nearest address number, direction of travel
36. Nearest Cross Road
38. Please explain what happened and how.
40. 
    
42. Vehicle Information
44. 
    
46. Vehicle Year*
48. Vehicle Make*
50. Vehicle Model*
52. Registration Number*
54. Plate Number Color
56. Registration Type*
    -- Select One --PassengerCommercialMotorcycleOther
58. State of Vehicle Registration*
60. 
    
62. Are you the vehicle owner?*

    1. Yes
    2. No
64. 
    
66. Your Contact Information
68. 
    
70. First Name*
72. Middle
74. Last Name*
76. Address*
78. Address 2
80. City/Town*
82. State*
84. Zip Code*
86. Telephone
88. Email*
90. 
    
92. Repair Cost (please provide the source for the estimate)
94. Supporting Document
96. 
    
98. Have you notified your insurance company?*
    -- Select One --YesNo
100. Insurance Company
102. 
     
104. This vehicle damage claim form may also be printed and mailed to:

     Town of Needham
     Vehicle Damage Claims
     Department of Finance
     Town Hall
     1471 Highland Avenue
     Needham, MA 02492

     (revised 02/07/2012)
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106. Submit Submit and Print

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