GENOA CHARTER TOWNSHIP
SEWAGE DISPOSAL SYSTEM EVENT 
NOTICE OF CLAIM 

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 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 of Claim timely, your claim will be denied.  

Name:_______________________________________________________________________
   
Address:_____________________________________________________________________
____________________________________________________________________________
Telephone:____________________________________________________________________
 
Date of Loss:_____________________________ Date Loss Discovered:___________________
 
Address of Damaged Property (If different from above):
_____________________________________________________________________________
_____________________________________________________________________________
Owner of Damaged Property:____________________________________________________
 
Description of Sewer Backup:___________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
 
Description of Damage to Building and/or Personal Property:_________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
 
Description of any Personal Injuries:______________________________________________
_____________________________________________________________________________
Return This Form To: Genoa Charter Township
Attn: Greg Tatara
2911 Dorr Road
Brighton, MI 48116
Municipal Office Use Only
Date Received:__________________________
Action Taken:________________________________________________________________________

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To present a claim, you will be required to provide the following items:

If you do not provide sufficient detail to support your claim, the items will lose much of their value. Reimbursement for the Actual Cash Value of damaged items is the maximum amount payable.
 
• Copies of receipts for cleaning costs, plumbing bills, or other bills.
• List of the damaged items and receipts to prove the ages of your items.
• Please make an attempt to provide pictures if possible, of anything you wish to claim that was damaged due to the sewer backup.