Claim Form

Claim for Money or Damages Against the City of San Rafael
Pursuant to Government Code section 911.2, all claims for injury or damage to persons or personal property must be presented to the City within six (6) months of the incident. Claims for all other damages, including damage to real property, must be presented within one (1) year of the incident.
A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person acting on his/her behalf and shall show the following:
1. Name and Address of Claimant
Claimant Name * Required
First Last
Claimant Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Claimant Phone * Required
Claimant Email
Enter Email Confirm Email
2. Name and address to which the person presenting the claim desires notices to be sent:
Mailing Name
First Last
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
3. The date, place and other circumstances of the occurrence or transaction which gave rise to the claim asserted:
Date of Occurence * Required
MM slash DD slash YYYY
Time of Occurrence

: Hours

Minutes

AM/PM AM/PM
Location of Occurrence * Required
Circumstances giving rise to this claim * Required
(What happened and how is the City at fault?)
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as it may be known at the time of the presentation of the claim * Required
(What are your damages or injuries?)
5. Name(s) of the public employee(s) causing the injury, damage, or loss, if known * Required
6. If amount claimed totals less than $10,000: State the dollar amount and basis for computation * Required
(amount of damage or injury and how you came to that amount):
If amount claimed exceeds $10,000: Do not state amount. Check one of the following boxes * Required
- Limited Civil Case (less than or equal to $35,000)
- Unlimited Civil Case (more than $35,000)
WARNING: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good faith and with reasonable cause.
Signature * Required
By entering your name you are electronically signing the claim.
First Last
Date * Required
MM slash DD slash YYYY
You are required to provide the information above in order to comply with Government Code §910.
In order to assist the City in its investigation of your claim, the following additional information is requested (but not required):
7. Claimant(s) Social Security Number(s): * Required
8. Claimant(s) Date(s) of Birth: * Required
9. Name, address and telephone number of any witnesses to the occurrence or transaction which gave rise to the claim asserted: * Required
10. Is the claim is related to an automobile accident? * Required
Claimant's Insurance Company * Required
Claimant's Insurance Company Telephone * Required
Claimant's Insurance Company Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Policy Number * Required
Insurance Broker/Agent * Required
Insurance Broker/Agent Phone
Insurance Broker/Agent Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Claimant Vehicle License Number * Required
Vehicle Make/Year * Required
Claimant Drivers License Number * Required
Claimant Drivers License Expiration * Required
MM slash DD slash YYYY
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.
Attachments
Drop files here or

Accepted file types: jpg, tif, gif, png, pdf, Max. file size: 50 MB.
Maximum file size - 50 mega bytes.
Signature * Required
By entering your name you are electronically signing the claim.
First Last
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Claim for Money or Damages Against the City of San Rafael

You are required to provide the information above in order to comply with Government Code §910.