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Claim for Damage

FIRST NAME OF CLAIMANT*
LAST NAME OF CLAIMANT*
ADDRESS
CITY
STATE
ZIP CODE
FIRST NAME OF PARENT OR GUARDIAN
Complete if this is a Claim for Minors.
LAST NAME OF PARENT OR GUARDIAN
ADDRESS
CITY
STATE
ZIP CODE
ADDRESS WHERE CLAIMANT DESIRES NOTICES TO BE SENT*
PHONE NUMBER*
EMAIL*
CLAIM DETAILS
Date and Time of Occurrence
Date and Time of Occurrence
Date and Time of Occurrence
Location where Damage or Injury Occurred
How did damage or injury occur? (Provide details)
What particular ACT or OMISSION do you claim caused the damage or injury?
Names of City employee(s) involved in accident, if any:
What DAMAGE or INJURIES do you claim resulted?
Provide details of damage or injuries claimed.
SUM YOU CLAIM ON THE ACCOUNT OF THE FOLLOWING:
Injuries
Property Damage
Other Sums Claimed
Other Details:
Provide complete details.
Insurance payments received, if any:
Name of Insurance Company:
EXPENDITURES
Date
Date
Item
Amount
Date
Date
Item
Amount
Date
Date
Item
Amount
WITNESS INFORMATION
First Name of Witness
Last Name of Witness
Address
City
State
Zip
Phone Number
Additional First Name of Witness
Additional Last Name of Witness
Address
City
State
Zip
Phone Number
MEDICAL INFORMATION
First Name of Doctor
Last Name Doctor
Names of Additional Doctors if Any:
Name of Hospital
Address1
City
State
Zip
Phone Number
NOTE: All Claims may be required to be examined as to their claim under oath. Presentation of a false claim with intent to defraud is a felony (Cal. Pen. Code Sec. 72)
Date Filed
Date Filed
Upload Estimates
Upload Pictures
Upload Additional Documents
Upload Diagram
Claim Form Diagram
Claim Form Diagram
Print and read carefully. Once completed, upload the form.

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