[City of Ontario] Liability Claim Form

CITY OF ONTARIO

CLAIM FOR DAMAGES TO PERSONS OR PROPERTY

Submittal Guidelines and Instructions:

Claims for death, injury to person or personal property must be filed no later than 6 months after occurrence. (Govt. Code Sec. 911.2)
Claims for damages to real property must be filed no later than 1 year after occurrence. (Gov. Code Sec. 911.2)
You must provide a response to each question; if it does not apply, please write N/A.
You must provide a digital signature where required below.
You may choose to submit your claim via this online submittal or file a hard copy with City Clerk / Records Management Department, 303 East B Street, Ontario, CA 91764 (Gov. Code Sec. 915a)IMPORTANT MESSAGE: Government Code section 910.2 requires a claimant to sign a claim that is presented to the City. As a result of the COVID-19 outbreak and social distancing requirements, the City is temporarily waiving the requirement for an original signature on the claim form. This is a temporary measure to allow individuals to file claims online in an effort to prevent the transmission of COVID-19. At an appropriate time, this temporary measure will be no longer be necessary and original signatures will again be required. False, misleading, incomplete or missing information may be grounds for delayed reviews and/or a rejection of claim. This document is subject to Public Disclosure.

Is this a claim involving a personal injury? If so, a SSN may be required.

Yes

Note: Effective January 1, 2010 the Medicare Secondary Payer Act (Federal Law) requires the City to report all claims involving payments for bodily injury and/or medical treatments to Medicare. As such, if you are seeking medical damages we may require your Social Security Number and your date of birth.

Social Security Numbers will not be required at this time but may need to be provided to the City upon request.

Date of Birth of Claimant

Primary Phone Number

Secondary Phone Number

Is the Preferred Mailing Address (for claims communications) different from the Home Address of Claimant?

yes

How and when did the DAMAGE or INJURY occur? Give complete facts, date, time of day, etc.

Police Reports # or case #, if applicable:

Police Report Number:

Case Number:

Where did the DAMAGE or INJURY occur? Use the diagram below if necessary. Give street names and numbers, measurements from landmarks, etc.

If applicable download the diagram below and mark it up to show where incident happened.

Show street names, direction of travel indicating North, South, East or West; indicate place of accident with an "X"; show address numbers or distance to street corners.

Once you've completed the mark up of the diagram, scan (or take a picture of) the document and upload it, in the upload documents section at the end of this form below.

If diagram does not apply to your situation, you may upload a drawing on a separate sheet, photos and/or other supporting documentation, in the section below.

What particular ACT or OMISSION do you claim caused the injury or damage?

If applicable, provide names of City Employees involved.

What DAMAGE or INJURY do you claim resulted? Be specific and complete.

Are you claiming monetary damages?

Yes

What AMOUNT do you claim for each item of injury or damage as a result of this claim? For property damage, provide 2 repair estimates.

Expenditures incurred on account of DAMAGE or INJURY. List date, item, amount and payee.

Insurance payments received, if any, and name, address and telephone number of insurance company.

Names, addresses and telephone numbers of witnesses, doctors, and/or hospitals:

Upload File(s) - photos, drawings, diagrams, repair estimates, receipts, etc to support your claim. (Please make sure to click blue upload button.)

Click Here to Upload

When using the file upload tool, you would have been asked to select a file(s) and complete the upload process by clicking upload.

Before proceeding, please carefully review that you have completed the file upload process.

If you are submitting the claim on behalf of claimant, please state relationship. For example: insurance carrier, legal counsel or business.

Relation to claimant:

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

I acknowledge that the information provided is complete, true and accurate.

Yes

Recaptcha Response

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You will be provided with a Receipt upon submission and will be asked to download a copy of your claim submittal. Please make sure to download, print or save this document as you may be required to submit Proof of Submittal during the claim review process. You will also be emailed a copy of this information. If you do not receive an email confirmation, please submit again as your claim may have not been properly submitted.

Receipt

You will be provided with a Receipt upon submission.