LIABILITY CLAIM FORM

LIABILITY CLAIM FORM
City Claim Reporting Form (For all Persons or Property)
FROM

City of Lynwood: 11330 Bullis Road Lynwood, CA 90262
ADMINISTRATOR

Adminsure: 1470 S. Valley Vista Dr, Suite 230 Diamond Bar, CA 91765
WARNING

-CLAIMS FOR DEATH, INJURY TO PERSON, OR TO PERSONAL PROPERTY, MUST BE FILED NO LATER THAN SIX (6) MONTHS AFTER THE OCCURRENCE (Gov. Code, Sec. 911.2

-CLAIMS FOR DAMAGES TO REAL PROPERTY MUST BE FILED NOT LATER THAN ONE (1) YEAR AFTER THE OCCURANCE (Gov. Code, Sec. 911.2

-READ ENTIRE CLAIM FORM BEFORE FILING.

-ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS.
Name of Claimant:*
Date of Birth:*

MonthDayYear
Date
Social Security No:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Give Address to which you desire notice or communication to be sent regarding this claim:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Date of Accident:*

MonthDayYear
Date
Time of Accident: *
Place of Accident:*
How did damage or injury occur? (Give full details)*
Were Sheriffs at the scene? Yes No File No. (If known):*
What particular act or omission do you claim caused the injury or damage? Give the name of the City employee causing the injury or damage, if known:*
Give total amount of claim (include estimate amount of any prospective injury or damage):*
How was the amount of claim computed? (Be specific. List doctor bills, wage rate repair estimates, etc.)*
Expenditures made on account of accident or injury (date and item):*
Name of address of witnesses, doctors and hospitals:*
PLEASE READ THE FOLLOWING CAREFULLY

For all accident claims, provide a diagram with the names of streets, including North, East, South and West; indicate place of accident by “X” and by showing house numbers or distance to street corners.

If City vehicle was involved, designate by letter “A” location of City vehicle when you first saw it, and by “B” location of yourself or your vehicle when you first saw City vehicle; location of City vehicle at the time of accident by “A-1” and location of yourself or your vehicle at the time of the accident by “B-1” and the point of impact by “X”.

I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF: AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HERE STATED UPON MY INFORMATION AND BELIEF: AND AS TO THOSE MATTERS I BELIEVE IT TO BE TRUE. I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Date*

MonthDayYear
Date
Signature*
Attach Copies of Photos, Receipts, Invoices or Two (2) Estimates*

Browse Files

Cancelof
Should be Empty:

LIABILITY CLAIM FORM

FROM

ADMINISTRATOR