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Claim Form Fillable-1

The document is a claim form for damages to person or property against the County of Riverside, outlining instructions for completion and submission. It requires detailed information about the claimant, the incident, damages incurred, and any involved county employees. The form emphasizes the legal time limits for filing claims and the necessity of a signature for validity.

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lp1401527
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55 views1 page

Claim Form Fillable-1

The document is a claim form for damages to person or property against the County of Riverside, outlining instructions for completion and submission. It requires detailed information about the claimant, the incident, damages incurred, and any involved county employees. The form emphasizes the legal time limits for filing claims and the necessity of a signature for validity.

Uploaded by

lp1401527
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

COUNTY OF RIVERSIDE CLAIM FOR DAMAGES TO PERSON OR PROPERTY

OFFICE USE ONLY


INSTRUCTIONS:
1. Read claim thoroughly.
2. Fill out claim as indicated; attach additional information if necessary.
3. This office needs the original completed claim form and clear readable copies
of attachments (if any) if originals are not available.
4. This claim form must be signed.
DELIVER OR U.S. MAIL TO: C L E R K O F T H E B O A R D O F S U P E R V I S O R S
ATTN: CLAIMS DIVISION
P.O. BOX 1147, 4080 LEMON ST, 1ST FL.
RIVERSIDE, CA. 92502-1147 (951) 955-1060 TIME STAMP HERE
1. FULL NAME OF CLAIMANT 8. WHY DO YOU CLAIM THE COUNTY IS RESPONSIBLE?

2. MAILING ADDRESS (STREET / PO BOX)

CITY STATE ZIP CODE

HOME TELEPHONE BUSINESS TELEPHONE 9. NAMES OF ANY COUNTY EMPLOYEES (AND THEIR DEPARTMENTS) INVOLVED IN
INJURY OR DAMAGE (IF APPLICABLE).
( ) ( )
3. WHEN DID DAMAGE OR INJURY OCCUR (PLEASE BE EXACT) NAME: DEPARTMENT:

4. WHERE DID DAMAGE OR INJURY OCCUR? 10. WITNESSESS TO DAMAGE OR INJURY: LIST ALL PERSONS AND ADDRESSES OF
PERSONS KNOWN TO HAVE INFORMATION:

STREET CITY STATE ZIP CODE NAME PHONE

5. DESCRIBE IN DETAIL HOW DAMAGE OR INJURY OCCURRED: ADDRESS

NAME PHONE

ADDRESS

NAME PHONE

ADDRESS

11. LIST DAMAGES INCURRED TO DATE (attach copies of receipts or repair estimates)

6. WERE POLICE OR PARAMEDICS CALLED? YES NO

7. IF PHYSICIAN/HOSPITAL WAS VISITED DUE TO INJURY, INCLUDE DATE OF FIRST VISIT


AND HOSPITAL’S NAME, ADDRESS AND PHONE NUMBER:

DATE OF FIRST VISIT PHYSICIAN’S/HOSPITAL’S NAME

PHYSICIAN’S/HOSPITAL’S ADDRESS PHONE:


TOTAL DAMAGES TO DATE TOTAL ESTIMATED PROSPECTIVE DAMAGES

( ) $_______________________ $_______________________________________

THIS CLAIM MUST BE SIGNED TO BE VALID. NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (PENAL CODE SECTION 72.)
WARNING:
¾ CLAIMS FOR DEATH, INJURY TO PERSON OR TO PERSONAL PROPERTY MUST BE FILED NOT LATER THAN SIX (6) MONTHS AFTER THE
OCCURRENCE. (GOVERNMENT CODE SECTION 911.2)

¾ ALL OTHER CLAIMS FOR DAMAGES MUST BE FILED NOT LATER THAN ONE (1) YEAR AFTER THE OCCURRENCE. (GOVERNMENT CODE SECTION
911.2)

¾ SUBJECT TO CERTAIN EXCEPTIONS. YOU HAVE ONLY SIX (6) MONTHS FROM THE DATE OF THE WRITTEN NOTICE OF REJECTION OF YOUR CLAIM
TO FILE A COURT ACTION. (GOVERNMENT CODE SECTION 945.6)

¾ IF WRITTEN NOTICE OF REJECTION OF YOUR CLAIM IS NOT GIVEN, YOU HAVE TWO (2) YEARS FROM ACCRUAL OF THE CAUSE OF ACTION TO FILE
A COURT ACTION. (GOVERNMENT CODE SECTION 945.6)

12. CLAIMANT OR PERSON FILING ON HIS/HER BEHALF 13. PRINT OR TYPE NAME DATE

 
SIGNATURE RELATIONSHIP TO CLAIMANT

COB 06/27/03 BGS REVISED: 7/20/2010

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