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Notice of Claim-Seweage Disposal or A Storm Water Event

This Notice of Claim form must be completed in full, and filed with the governmental agency against which you wish to make a claim for property damage or physical injury resulting from a sewage disposal or storm water system event.  Michigan Law requires that you file this written notification within 45 days after the damage or physical injury was discovered, or in the exercise of reasonable diligence should have been discovered.  If you fail to file your Notice ofClaim timely, your claim will be denied.

Name:


Address:


Contact Information: Phone Number/Email Address:


Date of Loss :


Date Loss Discovered:


Address of Damaged Property (If different from above):


Owner of Damaged Property (If different from above):


Description of Sewer Backup:




Description of Damage to Building:


And / Or Personal Property:


Description of Any Personal Injuries:


Municipal Office use only:

Date Received:


Action Taken: