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Claim Form

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NOTICE TO CLAIMANT

 In order for your claim to receive proper consideration you are requested to supply the information called for on this application form. All material facts should be stated on this form, as it will be the basis of further action upon your claim. The instructions set forth should be read carefully before the form is completed.

INSTRUCTIONS

 

Claims must be signed by the property owner, injured party, or the person representing the claim. Unsigned claim forms cannot be honored. See Government Code §910.2, the amount claimed must be sustained by competent evidence before a claim can be paid. Whether attached to the claim form, or submitted subsequently, evidence supporting the amount claimed may include: 

  1. In support of a claim for the personal injury or death, the claimant should submit documentation evidencing the injuries sustained, treatment rendered, the period of hospitalization, future treatment, the degrees of permanent disability, the prognosis, and

    evidence of medical bills received and paid. It is recommended that such medical evidence NOT be attached to the claim form, but

    that such substantiation of damages be provided upon request. The Claim Form and attachments thereto is a public record and subject to public inspection.

     

  2. In support of claims for damage to property which has been or can be economically repaired, submit at least two itemized signed repair estimates or statements of damage by reliable, disinterested persons, or if payment has been made, the itemized signed receipts evidencing payment.

     

  3. ln support of claim for lost property or property that cannot be economically repaired, submit documentation of the original cost of the property, the date of purchase, and the value of the property before and after the accident. The statements demonstrating the value of the property should be disinterested competent persons, preferably reputable dealers, persons familiar with the type of property, by two or more competitive bidders, or advertisements for the same or similar property.

The completed Claim Form must be mailed or delivered to the City Clerk's Department, 130 South Main Street, Lake Elsinore, CA, 92530. Questions or requests for further information should be directed to the City Clerk's Department at (951) 674-3124 ext. 269

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Claimant Information
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Claimant Information
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Claim Information
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Claim Information
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Insurance Coverage

Insurance Coverage
In order that claims may be properly adjusted by the City or your insurance company, it is essential that the claimant provide the above information regarding any insurance coverage available for the loss or injury.

CRIMINAL PENALTY FOR PRESENTING FRAUDULENT CLAIM OR MAKING FALSE STATEMENTS

Every person who, with intent to defraud, presents for allowance or payment any false or fraudulent claim against the City is guilty of a felony. (See California Penal Code §72)

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IDECALRE UNDER THE PENALTIES OF PURJURY OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS CORRECT AND THAT THE AMOUNT OF THIS CLAIM COVERS ONLY DAMAGES AND INJURIES CAUSED BY THE ACCIDENT DESCRIBED HEREIN.

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