Fillable CLAIM FOR DAMAGES, INJURY OR LOSS City of (City of Covina)

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CLAIM FOR DAMAGES, INJURY OR LOSS City of (City of Covina)

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The CLAIM FOR DAMAGES, INJURY OR LOSS City of (City of Covina) form is 1 page long and contains:

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CLAIM FOR DAMAGES, INJURY OR LOSS
TO: City Clerk Send Notices to: __________________________________________________
City of Covina
125 East College Street Address: ________________________________________________________
Covina, CA 91723
Telephone Number: _______________________________________________
_______________________________________________________________________________________________________
Name of Claimant Address of Claimant
_______________________________________________________________________________________________________
City/State/Zip Code Telephone #
Please complete the following and attach another page if more space is needed.
WHEN did damage, injury or loss occur? (Give exact date and hour)________________________________________________
LOCATION (exact) of damage, injury or loss._________________________________________________________________
CIRCUMSTANCES of occurrence (give full details).
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
NAME(s) of any public employee(s) causing injury/loss (if known).
_______________________________________________________________________________________________________
WHAT particular act or omission on the part of the City officers or employees do you claim caused the damage, injury or
loss?___________________________________________________________________________________________________
_______________________________________________________________________________________________________
WHAT damage, injury or loss do you claim resulted?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
AMOUNT claimed at present, including estimated amount of any prospective injury or loss insofar as known and basis for
determination. (If amount is greater than $10,000, specific dollar amount need not be included; however you must
indicate
whether dollar amount is more or less than $25,000.) Please attach any bills, receipts or estimates available.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Names, addresses and telephone numbers of witnesses, doctors and/or hospitals.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
____________________________ ___________________________________________________
Date SIGNATURE of Claimant or person acting on Claimant's behalf
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CLAIM FOR DAMAGES, INJURY OR LOSS City of (City of Covina)

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Completed 3 August 2020

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