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Liability Claim Against the City of Palmdale for Damages to Persons and Personal Property (See Government Code Sections 900 through 915.4 and Palmdale Municipal Code 3.12) Temporary Extensions under COVID-19 Order: Your time for presenting a claim under Government Code §911.2 may be extended by Executive Order by the Governor. (www.ca.gov) It is your responsibility to determine by which date your claim should be filed. Completed claims must be hand delivered or mailed to: Palmdale City Clerk 38300 Sierra Highway Suite, C. Palmdale, CA 93550 Claims by facsimile or email are not accepted. See CA Government Code § 915a. Office hours for the Palmdale City Clerk are: Monday – Thursday: 7:30 a.m. to 6:00 p.m. Friday, Saturday and Sunday: Closed. 2015 I City of Palmdale California Disclaimer: The instructions that follow are to assist you in filling out the attached claim form. These instructions are in no way intended to give legal advice. These instructions are not legal advice. If at anytime you feel the need for legal advice, at your own expense, you should consult a competent legal professional to assist you. Please be sure that your claim is with the City of Palmdale, California and not a distinct and separate California Public Entity such as: Palmdale School District, Palmdale Water District, the Los Angeles County, Los Angeles County Sheriff, etc. The City of Palmdale has no operational or jurisdictional control over these entities. It is your responsibility to ensure you are filing a claim with the cor- rect Public Entity. CLAIM FORM INSTRUCTIONS 1. Claimant Information: Complete Given Name. First, Middle, Last and suffix as applicable Jr., Sr., etc. Home address: Where you, the claimant, reside. Not your representative. Phone No. Your Phone Number. Date of Birth. SSN: Please see item #9 on the claim form reference MMSEA; Email: voluntary. Name of Parent or Guardian—if filing on behalf of a minor. 2. Representatives Information: Name, Address and Phone where notices should be sent if other than item #1 above; If repre- sented by an attorney, include their information. The more detail provided, the better we can communicate. 3. Incident: Date, Time and Location of Incident from which this claim arises. 4. Detailed Description of the Incident from which this claim arises (if more room is needed, please attach information on a sep- arate piece of paper): we need to understand what happened to properly investigate. Please provide as much detail as possi- ble. 5. Description of Damage, Injury or Loss Claimed: what are your damages, injury or loss claimed? Please be specific. 6. Cause of Action: Explain why you feel the City of Palmdale is responsible for your damages or injury: What did the City of Palmdale do or fail to do? 7. Name of City of Palmdale Employee or Department involved , if known. 8. Amount Claimed: Choose one. Enter amount if known. 9. Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) The reason we ask that you provide your SSN or HICN No. is explained here. The link above will take you to the website. 10. Witnesses: Anyone who observed the event that can be contacted as a witness, including their address and telephone number. 11. Responding Authorities: CHP, Sheriff, LA County Fire, Paramedics, Ambulance, etc. 12. Medical Providers: Where did you or are you treating for your injury? Who is paying your insurance bills? Please include your doctor’s name, address and telephone number as well as dates of treatment. 13. Motor Vehicle Accident: We must confirm your insurance. Please provide a copy of your proof of insurance. WARNING: Presentation of a false claim is a felony under CA PC § 72. At their discretion, the City of Palmdale may seek to recover all costs of defense in the event an action is filed which is later determined to not have been brought in good faith and with rea- sonable cause pursuant to: CCP 128.5 and 1038; the California False Claims Act GC §12650 and any other remedies available. You have a limited amount of time from date of incident to file this claim. Please refer to Government Code §911.2 to determine by which date your claim should be filed. Claim Form Instructions ---PAGE BREAK--- For Official Use Only Claim No. Date Stamp Received U.S. Mail Counter Courier Liability Claim Against the City of Palmdale California For Damages to Persons and Personal Property (See Government Code Sections 900 through 915.4 and Palmdale Municipal Code 3.12) Temporary Extensions under COVID –19 Order: Your time for presenting a claim under Government Code §911.2 may be extended by Executive Order of the Governor. (www.ca.gov) It is your responsibility to determine by which date your claim should be filed. Completed claims must be hand delivered or mailed to: Palmdale City Clerk 38300 Sierra Highway Suite, C. Palmdale, CA 93550 Claims by facsimile or email are not accepted. See CA Government Code § 915a. Office hours for the Palmdale City Clerk are: Monday – Thursday: 7:30 a.m. to 6:00 p.m. Friday, Saturday and Sunday: Closed. 4. Detailed Description of the Incident from which this claim arises (if more room is needed, please attach additional pages): Page 1 of 4 2015 I City of Palmdale California 2. Representative Information: Name: Address: Phone: Fax: Email: 3. Incident: Date, Time and Location of Incident from which this claim arises: Date: Location: Time: p.m. a.m. 1. Claimant Information: Date of Birth: SSN: Full Name: Home Address: Phone Number: Email: Name of Parent or Guardian: (If filing claim on behalf of a minor) ---PAGE BREAK--- 7. Name of any City of Palmdale Employee or Department involved (if known): Name: 2015 I City of Palmdale California Page 2 of 4 Liability Claim Against the City of Palmdale California for Damages to Persons and Personal Property (See Government Code Sections 900 through 915.4 and Palmdale Municipal Code 3.12) 5. Description of Damage, Injury or Loss Claimed: 6. Cause of Action: Explain why you feel the City of Palmdale is responsible for your damages or injury: 8. Amount Claimed: If the amount claimed is equal to or less than Ten Thousand Dollars ($10,000): As of the date of presentation of the claim, in- cluding the estimated amount of any prospective injury, damage (property damage requires two estimates) or loss, insofar as it may be known, submit your supporting documentation (i.e. bills, invoices, estimates etc.) and show how you arrived at the total amount claimed. If the amount claimed exceeds Ten Thousand Dollars ($10,000): No dollar amount needs to be included in the claim; howev- er, your claim must indicate whether it would be a limited civil case. A limited civil case is one where the recovery sought, exclusive of fees, interest and court costs, does not exceed Twenty Five Thousand Dollars ($25,000). An unlimited civil case is one in which recovery sought is more than Twenty Five Thousand Dollars (See CCP § 86). 8a. 8b. 8c. The amount claimed in this matter is indicated below (choose one): UNLIMITED CIVIL CASE LIMITED CIVIL CASE ≤ $10,000.00 To comply with the CA Government Code § 910 through 915.4 you are required to provide the information requested above. With regard to providing your SSN, see item 9 below. In order to conduct a timely investigation and work with you towards a pos- sible resolution of your claim, the City of Palmdale requests that you read, review and or answer the following: 9. Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) Effective January 1, 2010, the above Federal Act (MMSEA) requires all R.R.E.’s (Responsible Reporting Entities) that include the City of Palmdale to report all claims involving payments for bodily injury and or medical treatment relative to your claim with the City. As such, we are requesting you provide your Social Security Number (SSN) and or your Health Insurance Claim Number (HICN) as applicable. If you are receiving Medi-Cal benefits, we are required to report your claim to DCHS - California Department of Health Care Services. Not providing this information will delay your claim processing and any settlement you would be due. (Enter Dollar Amount if Known) ---PAGE BREAK--- 2015 I City of Palmdale California Page 3 of 4 Liability Claim Against the City of Palmdale California for Damages to Persons and Personal Property (See Government Code Sections 900 through 915.4 and Palmdale Municipal Code 3.12) 10. Name, Address and Phone Number of any Witnesses that Observed the Incident from which this claim arises: 11. Responding Authorities and or Emergency Medical Services (police, fire, ambulance) and report number (if known): 12. Medical Providers - Name, Address and Phone Number of any doctor, hospital or facility providing medical care: 13. Motor Vehicle Accident - if your claim relates to an MVA , provide the following information and attach proof of insurance: Insurance Company: Policy No. Claim No. Name of Contact: Phone No. Email: 14. Scene Diagram: To better assist us in our investigation and to pinpoint the subject location in question, to the best of your ability, draw the inci- dent scene (a diagram template is included in this packet) that includes relevant and identifiable landmarks including the cardi- nal direction NORTH as it relates to the scene; also include in your rendering: cross streets, road signs, other distinguishable markings, measurements, intersections, sidewalks, businesses etc. which will allow the City to properly investigate your claim. WARNING: Presentation of a false claim is a felony under CA PC § 72. At their discretion, the City of Palmdale may seek to recover all costs of defense in the event an action is filed which is later determined to not have been brought in good faith and with rea- sonable cause pursuant to: CCP 128.5 and 1038; the California False Claims Act GC §12650 and any other remedies available. You have a limited amount of time from date of incident to file this claim. Please refer to Government Code §911.2 to determine when you need to file your claim. The undersigned states that he or she is the person making the above stated claim and or is a person representing said claim and acting on behalf of the claimant above named and declares under the penalty of perjury under the Laws of the State of California that the foregoing is true and correct insofar as is known as of this date. Be advised: Palmdale Municipal Code 3.12.030 Form of Claim states: All claims shall be made in writing and verified by the claimant or by his or her guardian, conservator, executor or administrator. No other agent, including the claimant’s attorney, may sign the claim. No claim may be filed on behalf of a class of per- sons unless individually verified by every member of that class as required by this section. In addition, all claims shall contain the information required by California Government Code Section 910. (Ord. 1337 § 2, 2007) Signature: Date: (Indicate Relationship) (Print Name of Person Signing) (Signature) (Date Signed) ---PAGE BREAK--- Page 4 of 4 2015 I City of Palmdale California Incident Location Diagram Claimant Name: Location of Incident: