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CITY OF ONTARIO

303 East B Street Ontario, CA 91764

(909)395-2000

CITY OF ONTARIO

CLAIM FOR DAMAGES TO PERSONS OR PROPERTY

 Submittal Guidelines and Instructions:

  1. Claims for death, injury to person or personal property must be filed no later than 6 months after occurrence. (Govt. Code Sec. 911.2)
  2. Claims for damages to real property must be filed no later than 1 year after occurrence. (Gov. Code Sec. 911.2)
  3. You must provide a response to each question; if it does not apply, please write N/A.
  4. You must provide a digital signature where required below.  
  5. 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.

Name of Claimant


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

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.



Home Address of Claimant

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

Preferred Mailing Address (for claim communications)


Police Reports # or case #, if applicable:


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.

image




Are you claiming monetary damages?




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

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.


Be sure to verify that you are not a robot by using the Captcha tool at the below.
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I acknowledge that the information provided is complete, true and accurate.


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


Sign Here

Choose how to sign

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.