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Get City Of Oakland Pothole Claim

CLAIM AGAINST THE CITY OF OAKLAND Please return the completed form to the Office of the City Attorney One Frank H. Ogawa Plaza 6th Floor Oakland CA 94612. Additional sheets may be attached as necessary. Enclose a postage paid envelope if you require a filing receipt. 1 CLAIMANT S NAME 2 ADDRESS City State HOME DRIVER S LICENSE WORK SOCIAL SECURITY CELL DATE OF BIRTH OCCUPATION AUTO INSURANCE NAME AND POLICY if applicable Zip 3 IF AMOUNT CLAIMED IS LESS THAN 10 000 AMOUNT OF CLAIM Attach copies of expenses substantiating the basis of computation for the amount being claimed Yes No Unsure 4 ADDRESS TO WHICH NOTICES ARE TO BE SENT IF DIFFERENT FROM LINES 1 2 NAME PHONE 5 DATE OF INCIDENT TIME OF INCIDENT SPECIFIC LOCATION OF INCIDENT Address 6 DESCRIBE THE INCIDENT INCLUDING YOUR REASON FOR BELIEVING THE CITY IS LIABLE FOR YOUR DAMAGES 7 DESCRIBE ALL DAMAGES WHICH YOU BELIEVE YOU HAVE INCURRED AS A RESULT OF THE INCIDENT 8 NAME S OF PUBLIC EMPLOYEE S CAUSING THE DAMAGES YOU ARE CLAIMING 9 WERE PARAMEDICS CALLED 10 IF YOU WENT TO A DOCTOR LIST HIS NAME ADDRESS TELEPHONE NUMBER Date of 1st Visit X Signature of Claimant or Representative Is there a police report on file V A Date Complete the diagram on the back of this form showing the location of the incident Any person who with the intent to defraud presents any false or fraudulent claim may be punished by imprisonment or fine or both. Ogawa Plaza 6th Floor Oakland CA 94612. Additional sheets may be attached as necessary. Enclose a postage paid envelope if you require a filing receipt. 1 CLAIMANT S NAME 2 ADDRESS City State HOME DRIVER S LICENSE WORK SOCIAL SECURITY CELL DATE OF BIRTH OCCUPATION AUTO INSURANCE NAME AND POLICY if applicable Zip 3 IF AMOUNT CLAIMED IS LESS THAN 10 000 AMOUNT OF CLAIM Attach copies of expenses substantiating the basis of computation for the amount being claimed Yes No Unsure 4 ADDRESS TO WHICH NOTICES ARE TO BE SENT IF DIFFERENT FROM LINES 1 2 NAME PHONE 5 DATE OF INCIDENT TIME OF INCIDENT SPECIFIC LOCATION OF INCIDENT Address 6 DESCRIBE THE INCIDENT INCLUDING YOUR REASON FOR BELIEVING THE CITY IS LIABLE FOR YOUR DAMAGES 7 DESCRIBE ALL DAMAGES WHICH YOU BELIEVE YOU HAVE INCURRED AS A RESULT OF THE INCIDENT 8 NAME S OF PUBLIC EMPLOYEE S CAUSING THE DAMAGES YOU ARE CLAIMING 9 WERE PARAMEDICS CALLED 10 IF YOU WENT TO A DOCTOR LIST HIS NAME ADDRESS TELEPHONE NUMBER Date of 1st Visit X Signature of Claimant or Representative Is there a police report on file V A Date Complete the diagram on the back of this form showing the location of the incident Any person who with the intent to defraud presents any false or fraudulent claim may be punished by imprisonment or fine or both. PLEASE READ CAREFULLY If claim is for injury and you are still under doctor s care indicate that on the form and submit medical bills to date with status of your condition* If property damage is involved submit two estimates of repairs or paid invoices to substantiate amount claimed* If the accident involved a vehicle give the following information YEAR/MAKE OF THE VHEICLE LICENSE NO. .

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