Get CA Fresno SF3164 2006-2024

CLAIM FOR DAMAGES NOTE A claim relating to a cause of action for death or for injury to person or to personal property or grown crops shall be presented not later than six 6 months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one 1 year after the accrual of the cause of action. Refer to California Government Code Section 911. 2 INSTRUCTIONS Deliver or mail the completed claim form to City of Fresno Risk Management 2600 Fresno Street Room 1070 Fresno CA 93721-3612. CLAIM FOR DAMAGES NOTE A claim relating to a cause of action for death or for injury to person or to personal property or grown crops shall be presented not later than six 6 months after the accrual of the cause of action* A claim relating to any other cause of action shall be presented not later than one 1 year after the accrual of the cause of action* Refer to California Government Code Section 911. 2 INSTRUCTIONS Deliver or mail the completed claim form to City of Fresno Risk Management 2600 Fresno Street Room 1070 Fresno CA 93721-3612. Retain the pink copy for your records. Sign and date all attachments to the claim form* OFFICIAL USE ONLY Birthdate of Claimant Name of Claimant Injured or Damaged Party Home Address of Claimant City/State/Zip Code Home Telephone Number Business Address of Claimant Business Telephone Number Social Security Number of Claimant CA Drivers License Number Name of Person to whom any Notices concerning Claim should be sent If different from above Relationship to Claimant Address of Person to whom any Notices concerning Claim should be sent If different from above Telephone Number When did Injury Damage or Loss occur Date and Time Police Report Number How did Injury Damage or Loss occur Provide full details - Use separate sheets if necessary What did City or City Employee s do to cause the Injury Damage or Loss What are the name s of City Employee s who caused the Injury Damage or Loss If known Describe the Injury Damage or Loss claimed* Provide full details - Attach any medical records and use separate sheets if necessary. What is the amount of Injury Damage or Loss claimed including the estimated amount of any future Injury Damage or Loss. Itemize and attach medical bills property damage estimates etc*-Use separate sheets if necessary. If the amount claimed exceeds 10 000. 00 no dollar amount shall be included* However you shall indicate whether the claim would be a limited civil case. Refer to California Government Code Section 910 f Name Address Telephone Number of Witness es Doctor s and/or Hospital s. Use separate sheets if necessary. Signature of Claimant or Person acting on Claimant s behalf Date PRESENTATION OF A FALSE OR FRAUDULENT CLAIM IS A FELONY Refer to California Penal Code Section 72 SF3164 05/06. 2 INSTRUCTIONS Deliver or mail the completed claim form to City of Fresno Risk Management 2600 Fresno Street Room 1070 Fresno CA 93721-3612. Retain the pink copy for your records. Sign and date all attachments to the claim form* OFFICIAL USE ONLY Birthdate of Claimant Name of Claimant Injured or Damaged Party Home Address of Claimant City/State/Zip Code Home Telephone Number Business Address of Claimant Business Telephone Number Social Security Number of Claimant CA Drivers License Number Name of Person to whom any Notices concerning Claim should be sent If different from above Relationship to Claimant Address of Person to whom any Notices concerning Claim should be sent If different from above Telephone Number When did Injury Damage or Loss occur Date and Time Police Report Number How did Injury Damage or Loss occur Provide full details - Use separate sheets if necessary What did City or City Employee s do to cause the Injury Damage or Loss What are the name s of City Employee s who caused the Injury Damage or Loss If known Describe the Injury Damage or Loss claimed* Provide full details - Attach any medical records and use separate sheets if necessary. .