Government Claims Program Information And Claim Form Page 4
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4Location of the incident:
Describe the specific damage or injury:
Explain the circumstances that led to the damage or injury:
Explain why you believe the state is responsible for the damage or injury:
Does the claim involve a state vehicle?
Yes
No
If YES, provide the vehicle license number, if known:
Auto Insurance Information
Name of Insurance Carrier
Mailing Address
City
State
Zip
Policy Number:
Tel:
Are you the registered owner of the vehicle?
Yes
No
If NO, state name of owner:
Has a claim been filed with your insurance carrier, or will it be filed?
Yes
No
Have you received any payment for this damage or injury?
Yes
No
If yes, what amount did you receive?
Amount of deductible, if any:
Claimant’s Drivers License Number:
Vehicle License Number:
Make of Vehicle:
Model:
Year:
Vehicle ID Number:
Notice and Signature
I declare under penalty of perjury under the laws of the State of California that all the information I have
provided is true and correct to the best of my information and belief. I further understand that if I have
provided information that is false, intentionally incomplete, or misleading I may be charged with a felony
punishable by up to four years in state prison and/or a fine of up to $10,000 (Penal Code section 72).
Signature of Claimant or Representative
Date
Mail the original and two copies of this form and all attachments with the $25 filing fee or the “Filing Fee
Waiver Request” to: Government Claims Program, P.O. Box 3035, Sacramento, CA, 95812-3035. Forms can
also be delivered to the Victim Compensation and Government Claims Board, 400 R St., 5th flr, Sacramento.
For State Agency Use Only
Name of State Agency
Fund or Budget Act Appropriation No.
Name of Agency Budget Officer or Representative
Title
Signature
Date
VCGCB-GC-002 (Rev. 8/04)
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