Claim Form

Statutory requirements: Please note that claims for injuries or damages from a street or sidewalk defect must be received by the City within 30 days of the incident (M.G.L. c. 84). Any other negligence-based claims generally must be received by the City within 2 years of the incident (M.G.L. c. 258). For further information, Massachusetts General Laws are located on the State Legislature's website at

Claims must be filed in person at the Office of the City Clerk, 562 Main St., Melrose, MA, prior to the statute of limitation dates. Your claim will be forwarded to H.D. Segur Insurance.

Filing an incident claim:

  1. Complete a).Your statement of claim should include a thorough description of the incident, the exact location of the road/sidewalk/pothole defect or accident and the time and date.
  2. Include a repair receipt or itemized estimate of damages or injuries. Photos may be included.
  3. Include a Police Report if applicable.
  4. Any additional information you deem necessary (witnesses, motor vehicle info, etc.) may be attached to the claim form.
  5. File the completed paperwork in the Melrose City Clerk's office. 

Filing a claim:

  1. Complete the Notice of Claim Form  Include a description, exact location, time and date of the incident.
  2. Include any photos and police reports.
  3. Provide copies of receipts/estimates to repair the damage.
  4. File the completed paperwork in the Melrose City Clerk’s office.

Once the claim has been filed, the legal department forwards it to the insurance agency.  The City Clerk's office has no additional involvement in the process after accepting the filing.  All subsequent questions may be directed to:

H.D. Segur Insurance
Please note that the Insurance Agency requires sufficient time to complete the investigation of your claim