Claim Against The County Of San Diego (For Damages To Persons Or Personal Property)
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1
2CLAIM AGAINST THE COUNTY OF SAN DIEGO
(FOR DAMAGES TO PERSONS OR PERSONAL PROPERTY)
Received by
via
Time Stamp
U.S. Mail
Inter-Office Mail
Over the Counter
File No:
A claim must be filed with the Claims Division of the County of San Diego within 6 months after which the incident or event occurred. Be sure your claim
is against the County of San Diego, not another public entity. Where space is insufficient, please use additional paper and identify information by
paragraph and number. Completed claims must be mailed or delivered to:
County of San Diego, Claims Division, 1600 Pacific Highway, Room 355, San Diego, CA 92101- Phone (619) 531-4899
TO THE HONORABLE BOARD OF SUPERVISORS – THE COUNTY OF SAN DIEGO, CALIFORNIA
The undersigned respectfully submits the following claim and information relative to damage to persons and/or personal property:
Claimant Information
Last Name
First Name
Middle Name
Street Address
City
Zip
Home Phone (include area code)
Work Phone (include area code)
E-mail Address
Birth Date
Driver’s License Number
Name, telephone and post office address to which claimant desires notices to be sent, if other than above:
Claim Information
Date of Occurrence or Event from which the claim arises:
Time of Occurrence or Event from which the claim arises:
Location, including address (if none, nearest cross street) and city:
Specify the particular occurrence, event, act or omission you claim caused the injury or damage (use additional paper if
necessary):
State how or wherein the County of San Diego or its employees were at fault. Give the name(s) of the County department and
employee(s) causing the damage or injury:
CD1 (Rev. 6/11)
(Cont.)
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