City Of El Paso De Robles - Claim Form
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1
2CITY OF EL PASO DE ROBLES – CLAIM FORM
PLEASE READ INSTRUCTIONS ON OTHER SIDE BEFORE COMPLETION
Pursuant to Section 910 of the Government Code, claim is presented to the City of Paso Robles, California, as follows:
Name of Claimant
(First Name)
(Middle Initial)
(Last Name)
Home Address
Date of Birth
City, State, Zip
SSN
Mailing Address
CA DL #
(Street address)
(State)
(Zip Code)
(If different from above)
Daytime (
)
Evening (
)
Cell/Pgr (
)
TYPE OF LOSS
Personal Injury
Property Damage
Police Report #
Other
Indemnity-Date complaint served
When did injury or damage occur?
(Month/Day/Year)
(Day of Week)
(Time – AM? or PM?)
Where did injury or damage occur?
(street address, intersecting streets, or other location)
How did injury or damage occur?
(describe accident or occurrence)
What action or inaction of City employee(s) caused your injury or damage?
What injury or damage did you suffer?
Names of any witnesses
(Name)
(Address)
(Phone Number)
(Name)
(Address)
(Phone Number)
Name of City employee(s) involved
State the amount claimed for:
Personal Injury $_______________
Property Damage $
NOTE: Please attach copies of supporting documentation for the amounts claimed
,
ATTACH PROOF OF INSURANCE
IF CLAIM RELATES TO AN AUTOMOBILE ACCIDENT
PLEASE ANSWER THE FOLLOWING AND
Please check here if there was no insurance coverage in effect at time of incident
Insurance Policy #
Insurance Company
Insurance Broker/Agent
Address (street, city, state, zip)
WARNING: California State Law generally requires that most claims against a public entity, such as the City of Paso Robles, be presented within
SIX (6) MONTHS from the date of the action or incident giving rise to the claim. Certain other claims must be filed within ONE (1) YEAR from
the action or incident. You should check the Government Code to determine what presentation period applies in your case.
SIGNATURE
RELATIONSHIP (self, attorney, guardian, etc.)
DATE
Rev 6/03
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Parent category: Legal