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GOVERNMENT CLAIM STATE OF CALIFORNIA DEPARTMENT OF GENERAL (California)

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DEPARTMENT OF GENERAL SERVICES
OFFICE OF RISK AND INSURANCE MANAGEMENT
STATE OF CALIFORNIA
GOVERNMENT CLAIM
DGS ORIM 006 (Rev. 08/19)
CLAIMANT INFORMATION
LAST NAME
FIRST NAME
MIDDLE INITIAL
INMATE OR PATIENT IDENTIFICATION NUMBER (if applicable)
BUSINESS NAME(if applicable)
TELEPHONE NUMBER
EMAIL ADDRESS
MAILING ADDRESS
CITY
STATE
ZIP
IS THE CLAIMANT UNDER 18 YEARS OF AGE?
Yes No
INSURED NAME(Insurance Company Subrogation)
IS THIS AN AMENDMENT TO A PREVIOUSLY EXISTING CLAIM?
Yes No
EXISTING CLAIM NUMBER (if applicable)
EXISTING CLAIMANT NAME(if applicable)
ATTORNEY OR REPRESENTATIVE INFORMATION
LAST NAME
FIRST NAME
MIDDLEINITIAL
TELEPHONE NUMBER
EMAIL ADDRESS
MAILING ADDRESS
CITY
STATE
ZIP
CLAIM INFORMATION
STATE AGENCIES OR EMPLOYEES AGAINST WHOM THECLAIM IS FILED DATE OF INCIDENT
LATE CLAIM EXPLANATION (Required, if incident was more than six months ago)
CIVIL CASE TYPE(Required, if amount is more than $10, 000)
Limited ($25,000or less)
DOLLAR AMOUNT OF CLAIM
Non-Limited (over$25,000)
DOLLAR AMOUNT EXPLANATION
INCIDENT LOCATION
SPECIFIC DAMAGE OR INJURY DESCRIPTION
CIRCUMSTANCES THAT LED TO DAMAGE OR INJURY
EXPLAIN WHY YOU BELIEVE THE STATE IS RESPONSIBLE FOR THE DAMAGE OR INJURY
Page1 of 2
DEPARTMENT OF GENERAL SERVICES
OFFICE OF RISK AND INSURANCE MANAGEMENT
STATE OF CALIFORNIA
GOVERNMENT CLAIM
DGS ORIM 006 (Rev. 08/19)
AUTOMOBILE CLAIM INFORMATION
DOES THE CLAIM INVOLVE A STATE VEHICLE?
Yes No
VEHICLE LICENSE NUMBER(if known)
STATE DRIVER NAME (if known)
HAS A CLAIM BEEN FILED WITH YOUR INSURANCE CARRIER?
Yes No
INSURANCE CARRIER NAME INSURANCE CLAIM NUMBER
HAVE YOU RECEIVED AN INSURANCE PAYMENT FOR THIS DAMAGE OR INJURY?
Yes No
AMOUNT RECEIVED (if any) AMOUNT OF DEDUCTIBLE(if any)
NOTICE AND SIGNATURE
I declareunder penaltyof perjury under the laws of the State of Californiathat all the information I haveprovided is trueand correct to
the best of myinformation and belief.I further understand that if I haveprovided information that is false,intentionally incomplete,or
misleading I maybecharged with a felony punishable byup to four yearsinstate prisonand/or a fine of up to $10,000(PenalCode
section 72).
SIGNATURE
PRINTED NAME
DATE
INSTRUCTIONS
Include a check or moneyorder for $25, payable to the State of California.
$25filing fee is not required for amendments to existing claims.
Confirm allsectionsrelating to thisclaim arecompleteand the form is signed.
Attachcopiesof anydocumentation that supports your claim.Do not submit originals.
Mail the claim form and all attachments to:
Office of Risk and Insurance Management
Government Claims Program
P.O.Box 989052, MS414
West Sacramento,CA 95798-9052
Claim forms can also be delivered to:
Office of Risk and Insurance Management
Government Claims Program
707 3rd Street, 1st Floor
West Sacramento,CA 95605
1-800-955-0045
Department of General Services Privacy Notice on Information Collection
This notice is provided pursuant to the Information Practices Act of 1977, California Civil Code Sections1798.17&1798.24and the Federal
Privacy Act (Public Law93-579).
The Department of General Services(DGS),Office of Risk and Insurance Management (ORIM),is requesting the information specified on this
form pursuant to Government Code Section 905.2(c).
The principal purpose for requesting this data is to process claims against the state The information provided will/may be disclosed to a person,or
to another agency where the transfer is necessary for the transferee-agency to perform its constitutional or statutory duties,and the use is
compatible with a purpose for which the information was collected and the use or transfer is accounted for in accordance with California Civil Code
Section 1798.25.
Individuals should not provide personal information that is not requested.
The submission of all information requested is mandatory unless otherwise noted. If you fail to provide the information requested toDGS,or if the
information provided is deemed incomplete or unreadable, this may result in a delay in processing.
Department Privacy Policy
The information collected by DGS Is subject to the limitations in the Information Practices Act of 1977and state policy (see State Administrative
Manual 5310-5310.7). For more information on how we care for your personal information, please read the DGS PrivacyPolicy.
Access to Your Information
ORIM is responsible for maintaining collected records and retaining them for 5 years. You have a right to access records containing personal
information maintained by the state entity. To request access,contact:
DGSORIM
Public Records Officer
707 3
rd
St., West Sacramento,CA 95605
(916) 376-5300
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GOVERNMENT CLAIM STATE OF CALIFORNIA DEPARTMENT OF GENERAL (California)

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Completed 19 April 2021

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