Fairfax County, Virginia

CONTACT INFORMATION:

Risk Management Division
TTY 703-324-3040

12000 Government Center Parkway, Suite 215
Fairfax, VA 22035

Randy Jouben,
Risk Manager

Claim Note

Please use the tab key to complete this form.

Required fields are denoted with red asterisk * .

*Full Name:  

 

*Address (enter full mailing address)  

Street:

 

City:

 

Zip:

 

State:

 

*Telephone Number(home, work or cell):
 xxx-xxx-xxxx include area code

 

*E-mail Address:

 

*Date of Incident:
 (mm/dd/yyyy)

 

*Time of Incident:
 12-hour time (hh:mm)    AM PM   Please choose one.

 

*Location of Incident: (limit 400 characters)



 

*Brief Description of Incident: (limit 400 characters)

 

 

Damages/Injuries: (limit 400 characters)

 

 

   

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