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CITY OF PASADENA CLAIMS INFORMATION SHEET INSTRUCTIONS 1. (City of Pasadena - California)

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CITY OF PASADENA
CLAIMS INFORMATION SHEET
INSTRUCTIONS
1. Complete the attached claim form by typewriter or in black ink.
2. Answer each inquiry on the claim form, providing full details for each.
3. Sign and date the claim on page 3.
4. Present a claim for death, personal injury or personal property damage within six months of the incident to
the City Clerk’s Office, 100 N. Garfield Ave. Room S228, P.O Box 7115 Pasadena, CA 91109-7215. See
Government Code Section 911.2 for other time limitations.
INFORMATION
1. The claim will be r
eceived by the City Council and forwarded to the City’s Insurance and Claims
Specialist for investigation, processing and possible resolution.
2. If your claim was filed within the time permitted by law, State law requires that your claim is automatically
deemed denied by operation of law 45 days after the filing date. See California Government Code Section
912.4. The City will send you a notice of such denial automatically after 45 days have passed from the date
you filed your claim.
A word of clarification regarding automatic 45-day rejection notice is in order. This 45-day rejection notice is
sent without regard to the investigation or settlement status of your claim, since it is a State-mandated
rejection notice. Investigation or settlement discussion you may reach after such automatic 45-day notice is
not affected by this 45-day rejection notice.
The 45-day rejection notice will advise you that you have only six months thereafter to file a lawsuit.
Although review of your claim by the City, and settlement discussions with the City, may well continue
after the 45-day rejection notice and during this six-month period, the six-month filing deadline is binding;
you must comply with this six-month Statue of Limitations if your case if not resolved prior to expiration of
the six-month period. See Government Code Sections 913 and 945.6.
3. The City of Pasadena will seek to recover all costs of defense, including attorney’s fees and City resources
used in defending the case, in the event a lawsuit is filed against the City and it is determined that the lawsuit
was not brought in good faith and based on reasonable cause. See California Code of Civil, Procedure Sections
128.5, 1021.7 and 1038.
4. The submission of a false claim is a crime. See Section 72 of the California Penal Code.
5. Receipt of a claim form assignment of a “claim” number by the City Clerk does not waive any right the City
may have to object to the sufficiency or timeliness of the claim, or any portion thereof.
6. If you have any questions, please call Insurance and Claims Specialist at (626) 744-6773.
City Clerk
(Rev. 11/18)
Received via
U.S. Mail q
Inter-Office Mail
q
Over the Counter
q
Date:
Time:
SIGNATURE OF EMPLOYEE ACCEPTING CLAIM
CLAIM #
1. NAME OF CLAIMANT:
a. ADDRESS OF CLAIMANT: City: ZIP CODE:
b. PHONE NO. ( _) ________________ c. BUS. PHONE NO. ( _ ) ________________ d. DATE OF BIRTH
e. SOCIAL SECURITY NO. f. DRIVER'S LIC. NO. ( )
2. Name, telephone and post office address to which claimant desires notices to be sent if other than above:
3. Occurrence or event from which the claim arises (see Government Code § 910c and d):
a. DATE: b. TIME: c. PLACE (state exact and specific
location, including distances from known objects):
d. State the circumstances of the occurrence, transaction, act or defect you claim caused the injury or damage (use additional paper
if necessary). State details describing any hazardous condition or wrongful actions of any City employee. Include measurements
(including height, width and depth) of any property defect. Attach available photographs.
CLAIM AGAINST THE CITY OF PASADENA
(FOR DAMAGES TO PERSONS OR PERSONAL PROPERTY)
FOR CITY USE - DO NOT WRITE IN THIS AREA
A claim must be filed with the City Clerk's Office of the City of Pasadena no later than six (6) months after the incident
or occurrence for death, injury to person or damage to personal property. Be sure your cause of action is against the City
of Pasadena, not another public entity. Where space is insufficient, please use additional paper and identify information
by paragraph number. All blanks must be completed. Completed claims must be mailed or delivered to: City Clerk,
100 N. Garfield Ave., Room S228, P.O. Box 7115 Pasadena, California 91109-7215. See Government Code § 911.2 and
Pasadena City Charter § 1011 for filing information on other types of claims.
TO: The Council Members of the City of Pasadena, California
The undersigned respectfully submits the following claim:
1
STR0081 (Rev. 02/13)
FOR MOTOR VEHICLE ACCIDENTS
INDICATE
NORTH
CURB
CURB
FOR OTHER ACCIDENTS
SIDEWALK
PARKWAY
SIDEWALK
f. State exactly how the injury or damage occurred:
4. Give the name(s) of the City employee(s) causing the damage or injury if known (see Government Code § 910e):
READ CAREFULLY
For all non-vehicle accident claims place names of streets (including North, East, South, and West) on the following
diagram, and indicate place of accident by "X" and by showing house numbers or distances to street corners or known
objects.
If a vehicle was involved, identify location on the diagram of City or other vehicle when you first saw it by letter "A";
location of yourself or your vehicle when you first saw City or other vehicle by letter "B"; and the point of impact by "X".
Please use a box such as
A
or
B
to represent a vehicle.
NOTE: If diagrams below do not fit the situation, attach a proper diagram signed by claimant.
2
STR0081 (Rev. 02/13)
5. Give a description of the injury, property damage, loss or indebtedness, so far as is known at the time of this claim. If there
were no personal injuries, state "no injuries" (see Government Code § 910d):
b. If over $10,000, check either:
(1) under $25,000 (Municipal Court jurisdiction)
(2) over $25,000 (Superior Court jurisdiction)
7. Names, addresses and telephone numbers of all witnesses, hospitals, doctors, other persons injured, property owners, etc.:
a.
b.
c.
d.
e.
6. Damages claimed (see Government Code § 910f):
a. If under $10,000, complete the following:
(1) Amount claimed as of this date:
$
(2) Estimated amount of future costs: $
(3) Total amount claimed: $
(4) Basis of computation of amounts (include copies of all bills, invoices, estimates, etc.):
8. Any additional information that might be helpful in considering the claim:
CRIMINAL PENALTY FOR PRESENTING FRAUDULENT CLAIM OR MAKING FALSE STATEMENTS. Every person who, with
intent to defraud, presents any false claim or writing to the City for payment may be subject to imprisonment in a state prison and
a fine of $10,000 (Penal Code § 72).
I have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as
to those matters stated upon information or belief, and as to such matters I believe the same to be true. I certify under penalty of
perjury that the foregoing is TRUE and CORRECT.
Signed this day of , 20 .
at
CLAIMANT'S SIGNATURE
PRINTED OR TYPED NAME
3
STR0081 (Rev. 02/13)
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CITY OF PASADENA CLAIMS INFORMATION SHEET INSTRUCTIONS 1. (City of Pasadena - California)

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Completed 11 March 2021

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