2. 
4. FIRST NAME OF CLAIMANT*
5. LAST NAME OF CLAIMANT*
7. ADDRESS
8. CITY
9. STATE
10. ZIP CODE
12. FIRST NAME OF PARENT OR GUARDIAN
    Complete if this is a Claim for Minors.
13. LAST NAME OF PARENT OR GUARDIAN
15. ADDRESS
16. CITY
17. STATE
18. ZIP CODE
20. ADDRESS WHERE CLAIMANT DESIRES NOTICES TO BE SENT*
22. PHONE NUMBER*
23. EMAIL*
27. CLAIM DETAILS
29. Date and Time of Occurrence
    Date and Time of Occurrence

    Date and Time of Occurrence
30. Location where Damage or Injury Occurred
32. How did damage or injury occur? (Provide details)
34. What particular ACT or OMISSION do you claim caused the damage or injury?
36. Names of City employee(s) involved in accident, if any:
38. What DAMAGE or INJURIES do you claim resulted?
    Provide details of damage or injuries claimed.
42. SUM YOU CLAIM ON THE ACCOUNT OF THE FOLLOWING:
44. Injuries
45. Property Damage
46. Other Sums Claimed
48. Other Details:
    Provide complete details.
50. Insurance payments received, if any:
51. Name of Insurance Company:
53. EXPENDITURES
55. Date
    Date
56. Item
57. Amount
59. Date
    Date
60. Item
61. Amount
63. Date
    Date
64. Item
65. Amount
69. WITNESS INFORMATION
71. First Name of Witness
72. Last Name of Witness
74. Address
75. City
76. State
77. Zip
79. Phone Number
81. Additional First Name of Witness
82. Additional Last Name of Witness
84. Address
85. City
86. State
87. Zip
89. Phone Number
93. MEDICAL INFORMATION
95. First Name of Doctor
96. Last Name Doctor
98. Names of Additional Doctors if Any:
99. Name of Hospital
101. Address1
102. City
103. State
104. Zip
106. Phone Number
108. 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)
110. Date Filed
     Date Filed
114. Upload Estimates
115. Upload Pictures
116. Upload Additional Documents
118. Upload Diagram
119. Claim Form Diagram
     Claim Form Diagram

     Print and read carefully. Once completed, upload the form.
Leave This Blank:


121. 1. Receive an email copy of this form.
122. Email address

     This field is not part of the form submission.

123. Submit

* indicates a required field