Form Center

Step One

ANSWER ALL QUESTIONS, OMITTING INFORMATION COULD MAKE YOUR CLAIM LEGALLY INSUFFICIENT
Claimant
Name*
Email Address
Address*
City
State
Zip Code
Phone Number*
Witness Contact
List name, address and phone number of any witnesses.
Continue

Date and Time of Occurrence*
Date and Time of Occurrence
Date and Time of Occurrence
Place of Occurrence*
Circumstances
Tell What Happened (Give complete information)
Upload
Attach any photographs or documents you may have regarding this claim
Continue |Go Back

General Description*
Give a general description of the indebtedness, obligation, injury, damage or loss incurred so far as it may be known at the time of presentation of the claim.
People Involved
Give the name or names of the public employee or employees causing the injury, damage or loss if known.
Amount Claimed
The amount claimed if it totals less than ten thousand dollars ($10,000) as of the date of presentation of the claim, including the estimated amount of any prospective injury, damage or loss, insofar as it may be known at the time of the presentation of the claim, together with the basis or computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000), no dollar amount shall be include in the claim. However, it shall indicate whether the claim would be a limited civil case.
Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Date
Date

Leave This Blank: