Information And Claim Form (Page 2 of 4) in pdf

Describe the relationship of the attorney or representative to the claimant.

State the exact date of the incident that you believe caused the damage or injury. If the incident took place over

more than one date, provide both the beginning and ending dates. If the incident is ongoing, please provide the

beginning date and the most recent date it occurred.

Late Claims:

•

The State Bar must receive claims relating to the death or injury of a person, or damage to personal

property, no later than six months after the date of the incident. If such a claim is filed more than six

months from the date of the incident, attach a written explanation for the late filing of the claim on a

separate sheet of paper. In some instances leave to present a late claim may be granted.

•

Claims relating to any other cause of action must be received no later than one year after the date of the

incident.

•

Claimants may wish to consult with an attorney to determine which filing deadline applies.

State the name of employees against whom the claim is filed, if any.

Enter the total dollar amount being claimed. If you believe the damages are continuing, or anticipated in the

future, show a “+” after the dollar amount. If the total dollar amount exceeds $10,000, note whether the claim is a

limited civil case or a non-limited civil case. Provide an explanation of how you computed the total amount. You

may declare expenses incurred as well as expenses you expect to have in the future. Attach copies of all bills,

payment receipts, and cost estimates. Retain a copy of all bills, payment receipts, and cost estimates for

your own records.

For all claims involving real property, provide the street address where you believe the damage or injury

occurred. Real property includes land, buildings and other fixed structures.

Describe the specific damage or injury that you believe resulted from the incident. Feel free to attach additional

information to explain 16 through 18.

Describe in full detail the circumstances that led up to the damage or injury. State all the facts that support your

claim. If it applies, describe the dangerous condition of the public property.

Explain why you believe The State Bar of California is responsible for the damage or injury.

The claimant or the claimant’s attorney or representative must sign this form. The State Bar of California will not

accept the claim without an original signature.

The claimant must send or deliver three copies of the claim, along with three copies of all supporting

documentation to the State Bar’s Claims Officer.

State Bar Claim Form (last revised November 2005)

Information And Claim Form Page 2