Claim For Damages

Claimant
  First   Middle   Last   Suffix
Birth Date of Claimant (mm/dd/yyyy)
Email Address
Sex
Male    Female
Home Address of Claimant
City
  State
Zip Code
Home Telephone Number
Business Address of Claimant
City
  State
Zip Code
Business Telephone Number
Give address to which you desire notices or communications to be sent regarding this claim
City
  State
Zip Code
How did DAMAGE or INJURY occur? Please include as much detail as possible.
When did DAMAGE or INJURY occur? Please include the date and time of the damage or injury. (mm/dd/yyyy)
Where did DAMAGE or INJURY occur? For all accident claims, please upload a picture of a hand drawn diagram with the street names and addresses or measurements from specific landmarks.
Street
City
  State
Zip
What particular ACT or OMISSION do you claim caused the injury or damage? Please give names of City employees causing the injury or damage and identity any vehicles involved by license plate number, if known.
What DAMAGE or INJURIES do you claim resulted? Please give full extent of injuries or damages claimed
What is the AMOUNT of your claim?
Please itemize your damages
Attorney Information:
Name Prefix
First Name (or Company)
Middle
  Last
Suffix
Address
City
  State
Zip Code
Phone
Email
Please list names and addresses of Witnesses, Doctors and Hospitals:
Type
Name Prefix
First Name (or Company)
Middle
  Last
Suffix
Address
City
  State
Zip Code
Type
Name Prefix
First Name (or Company)
Middle
  Last
Suffix
Address
City
  State
Zip Code
Type
Name Prefix
First Name (or Company)
Middle
  Last
Suffix
Address
City
  State
Zip Code
If you have received any insurance payments, please give the names of the insurance companies
For all accident claims, please upload a diagram or simple sketch, including street names, of the streets where the accident occurred, and the nearest cross streets. Indicate the place of the accident by an “X” and by showing the nearest address and distances to street corners. Please indicate where North is on the diagram. Attach your diagram by clicking on the button below.
Attach your diagram
Please sign above
 
 
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Warning
  • CLAIMS FOR DEATH, INJURY TO PERSON OR TO PERSONAL PROPERTY MUST BE FILED NOT LATER THAN 6 MONTHS AFTER THE OCCURENCE. (GOVERNMENT CODE SECTION 911.2)
  • ALL OTHER CLAIMS FOR DAMAGES MUST BE FILED NOT LATER THAN ONE YEAR AFTER THE OCCURENCE. (GOVERNMENT CODE SECTION 911.2)
  • SUBJECT TO CERTAIN EXCEPTIONS, YOU HAVE ONLY SIX (6) MONTHS FROM THE DATE OF THE WRITTEN NOTICE OF REJECTION OF YOUR CLAIM TO FILE A COURT ACTION. (GOVERNMENT CODE SECTION 945.6)
  • IF WRITTEN NOTICE OF REJECTION OF YOUR CLAIM IS NOT GIVEN, YOU HAVE TWO (2) YEARS FROM ACCRUAL OF THE CAUSE OF ACTION TO FILE A COURT ACTION. (GOVERNMENT CODE SECTION 945.6)