303 East B Street
Ontario, CA 91764
Submittal Guidelines and Instructions:
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.
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.
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.
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.