CLAIM AGAINST THE by notoriousbig

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									                                 REVISED CLAIMS PROCEDURE


January 22, 2004

To:           JPA Representatives

From:         Rick Rinear, JPA Risk Management

Subject:      Tort Claim Reporting Form – Revised

We would like to clarify the Tort Claim Reporting procedure, as there has been some confusion
about requiring all potential claimants to use a district-written Claim Form.

Effective April 1, 2003, Government Code Section 910.4 (a) requires public entities to provide a
standardized Tort Claim Form that claimants use to file their claims for submission to districts.
The standard Claim Form (sample attached), must include information specified in Government
Code Section 910 and 910.2. Districts can still consider claims “submitted” without the required
form. Districts may consider a written claim without requiring the referenced claim form. The
referenced claim form must be available when requested.

We are providing a sample Cover Letter for potential claimants who request the required form.

Careful review of a claim is necessary for compliance or late filing. If considered insufficient
(not in compliance), the claim must be returned to claimant within 20 days from receipt. If a
claim is submitted in letter format and is sufficient (in compliance), per the Government Code,
the claim should be handled as if submitted on the district’s Claim Form; i.e., returned as
insufficient, late or rejected. The enclosed sample letter should only be used to forward a claim
form to those claimants who request a form from the district.

A sample Tort Claim Form complying with Government Code 910.4 (a) is also enclosed. Please
continue to forward claims when received to San Diego County Schools Risk Management JPA,
6401 Linda Vista Road, Room 505, San Diego, CA. 92111, Attention: Rodger Hartnett, Property
& Liability JPA Claims Coordinator. Rodger or Lisa Adriance-Jensen will recommend what
action to take. Rodger’s telephone number is 858-569-5428; Lisa’s telephone number is 858-
569-5453.

Please call me @ 858-292-3871 with questions.

RR:st

Enclosures
                                       SAMPLE

                          (Send Out When Claim Form Requested)




[Date]


[Addressee]




Subject:       Tort Claim Form Requirements

Dear ___________:

Government Code Section 910.4(a) requires claimants wishing to submit a claim against the
__________________District complete a Claim Form. A Claim Form for your completion is
attached.

The Government Code has claim-submission timelines, so please submit your claim
immediately.

Please direct questions to: ________________________ at _______________________.

Thank you for your cooperation.

Sincerely,



[Person writing letter]
CLAIM AGAINST THE                                                                                     SCHOOL DISTRICT
                DISTRICT NAME:
                ADDRESS:
                ATTN:


NAME OF CLAIMANT                                   MAILING ADDRESS                        ZIP                  TELEPHONE


                                                      INSTRUCTIONS
Claims against the above school district must be filed with the Board of Education within six (6) months after incident occurred,
as required by Government Code Section 911.2.
Where space is insufficient, please use additional paper, include your name, identify each item of information by the paragraph
number and sign each sheet.
1.                       OCCURRENCE OR TRANSACTION CAUSING THIS CLAIM
DATE                                                        TIME                                               PLACE


     2.                                            STATEMENT OF INCIDENT
                    (Specify the particular act or omission you claim caused the injury, damage or loss, if known.)




3.                                      DESCRIPTION OF CIRCUMSTANCES
STATEMENT OF HOW THE DISTRICT OR ITS EMPLOYEES WERE AT FAULT
(include names of persons causing injury damage or loss – if not known, state “not known.”)


4.        DESCRIPTION OF INCURRED INDEBTEDNESS, OBLIGATION, INJURY, DAMAGE
          OR LOSS
a. GENERAL DESCRIPTION:                                     c. NAME OF PERSON INJURED
  (So far as known as of the date of this claim)
                                                               DESCRIPTION OF PERSONAL INJURY

b. NAME OF PERSONS/s CAUSING THE ABOVE                      d. NAME OF PROPERTY OWNER
                                                               DESCRIPTION OF PROPERTY DAMAGED



5.                                                          CLAIM
     a.   AMOUNT CLAIMED AS OF DATE OF THIS                           c. TOTAL AMOUNT OF CLAIM: $
          CLAIM:                   $                                     (Attach estimates or bills in support of claim.)
     b.   ESTIMATED AMOUNT OF
          ANY PROSPECTIVE INJURY,                                     d. BASIS OF COMPUTATION OF AMOUNT CLAIMED
          DAMAGE OR LOSS.          $


6.                            EYEWITNESSES, ATTENDING PHYSICIAN, HOSPITAL,ETC.
     NAME                                                   ADDRESS                                            TELEPHONE




I certify under penalty of perjury that I know the          SIGNATURE OF CLAIMANT                              DATE OF CLAIM
above to be true and correct of my own knowledge.



               (IF MORE SPACE IS NEEDED, PLEASE ATTACH ADDITIONAL PAGES AS NECESSARY.)

								
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