CITY OF WEST HOLLYWOOD

CLAIM FOR DAMAGES TO PERSON OR PROPERTY

1.Claims for death, injury to person or to personal property must be filed not later than six months after the occurrence. (Gov. Code Sec. 911.2)

2. Claims for damages to real property must be filed not later than 1 year after the occurrence. (Gov. Code Sec. 911.2)

3. Read entire claim form before filing.

4. See section below for diagram upon which to locate place of accident.

5. This claim form must be signed at the bottom.

6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.

Claimant Information:

Name of Claimant

Occupation of Claimant

Date of Birth of Claimant

Home Address of Claimant

Home Telephone Number

Claimant Email Address

Business Address of Claimant

Business Telephone Number

Give address and telephone number to which you desire notices or communications to be sent regarding this claim:

Claim Information

When did DAMAGE or INJURY occur?

Time DAMAGE or INJURY occurred.

If claim is for Equitable Indemnity, give date claimant served with the complaint:

Names of any city employees involved in INJURY or DAMAGE

Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram below. Where appropriate, give street namesand addresses and measurements from landmarks:

READ CAREFULLY

For all accident claims place on following diagram the names of streets, including North, East, South, and West; Indicate place of accident by “X” and by showing house numbers or distances 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 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”. NOTE: If diagrams below do not fit the situation, attach hereto a proper diagram signed by claimant.

Location of Injury or damage

Select a brush color: Font Color

Select a stroke width:

Describe in detail how the DAMAGE or INJURY occurred

Why do you claim the City is responsible

Describe in detail each INJURY or DAMAGE

Damages

The amount claimed, as of the date of presentation of this claim, is computed as follows:

List damages incurred to date (exact):

Damage to property (enter a dollar amount)

Future expenses for medical and hospital care (enter a dollar amount)

Expenses for Medical and hospital care (enter a dollar amount)

Future loss of earnings (enter a dollar amount)

Loss of earnings (enter a dollar amount)

Other prospective special damages (enter a dollar amount)

Special damages for (enter a dollar amount)

Prospective general damages (enter a dollar amount)

General Damages (enter a dollar amount)

Total estimate prospective damages (enter a dollar amount)

Total damages incurred to date (enter a dollar amount)

TOTAL AMOUNT CLAIMED AS OF DATE OF PRESENTATION OF THIS CLAIM (enter a dollar amount)

Was damage and or injury investigated by police?

If so what City

Were paramedics or ambulance called?

If so name City or ambulance:

If injured, state date, time, name and address of doctor of your first visit

Witness Information

Witness #1

Witness 1 Name

Witness 1 Address

Witness 1 Phone

Witness #2

Witness 2 Name

Witness 2 Address

Witness 2 Phone

Witness #3

Witness 3 Name

Witness 3 Address

Witness 3 Phone

Hospitalization Questions

Hospital

Hospital Address

Date Hospitalized

Doctor

Doctor Address

Date of Treatment

Doctor #2

Doctor #2 Address

Doctor #2 Date of Treatment

Upload any additional file(s) or documentation pertinent to this Claim

Click Here to Upload

Document Signers

- Claimant
- West Hollywood City Clerk