HomeMy WebLinkAbout2004-23 form adoption, claims against cityRESOLUTION NO. 2004-23
RESOLUTION OF THE CITY COUNCIL OF THE
CITY OF UKIAH ADOPTING A FORM FOR
PRESENTING DAMAGES CLAIMS AGAINST
THE CITY AND REQUIRING THE USE OF THE
FORM BY CLAIMANTS
WHEREAS,
1. Prior to the adoption of Government Code Section 910.4, which became effective
on March 30, 2003, a claim for damages could be filed with the City as long as it
substantially complied with Government Code Section 910 by containing the information
required by that section; and
2. Effective March 30, 2003, Government Code Section 910.4 authorizes the City
Council to require a claimant to use a claim form adopted by the City of Ukiah, when
submitting a claim for damages to the City; and
3. It will improve the efficiency of the City in reviewing and acting on claims if a
standard form is used by each claimant and will result in the equal treatment of all claimants
NOW, THEREFORE, BE IT RESOLVED that:
1. The claim form attached hereto as Exhibit A is hereby adopted as the City of
Ukiah's form for submitting damages claims to the City.
2. All claims for damages must be submitted on the adopted City claim form. The
City Clerk is directed to refuse to file any claim that is not submitted using the adopted form.
In notifying a claimant of this requirement, the City Clerk shall offer the claimant a copy of
the adopted form for his or her use in submitting a claim.
PASSED AND ADOPTED on February 18, 2004 by the following roll call vote:
AYES:
NOES: None.
ABSENT: Councilmember Smith
ABSTAIN: None
ATTEST:
Councilmembers Rodin, Andersen, Baldwin, and Mayor Larson
Eric Larson, Mayor
Marie [Jlvila, Deputy City Clerk
File With:
City Clerk's Office
City of Ukiah
300 Seminary Ave
Ukiah, CA 95482
EXHIBIT A
CLAIM FOR MONEY OR
DAMAGES AGAINST
THE CITY OF UKIAH
RESERVE FOR FILING STAMP
CLAIM NO.
A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall show the following:
If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s)
being answered.
1. Name and address of the Claimant:
Name of Claimant:
Address:
.
Address to which the person presenting the claim desires notices to be sent:
Name of Addressee: Telephone:
Address:
.
The date, place and other circumstances of the occurrence or transaction which gave rise to the claim asserted.
Date of Occurrence: Time of Occurrence:
Location:
Circumstances giving rise to this claim:
.
General description of the indebtedness, obligation, injury, damage or loss incurred so far as it may be known at
the time of the presentation of the claim.
5. The name or names of the public employee or employees causing the injury, damage, or loss, if known.
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.
If amount claimed totals less than $10,000: 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 of
computation of the amount claimed.
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), no dollar
amount shall be included in the claim. However, it shall indicate whether the claim would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86.)
-~ Limited Civil Case
-'] Unlimited Civil Case
IYou are required to provide the information requested .above in order to comply with Government Codel
§910.
I
7. Claimant(s) Social Security Number(s): (optional)
8. Claimant(s) Date(s) of Birth:
.
Name, address and telephone number of any witnesses to the occurrence or transaction which gave rise to the
claim asserted:
10.
If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
11.
If applicable, please attach any medical bills or reports or similar documents supporting your claim.
If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.
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READ CAREFULLY
For all accident claims, place on the following diagram the name
of streets, including North, East, South, and West; indicate place
of accident by "X" and by showing house numbers or distances to
street corners. If City of Ukiah vehicle was involved, designate
by letter "A" location of City of Ukiah vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
City of Ukiah vehicle; location of City of Ukiah vehicle at time of
accident by "A-l" and location of yourself or your vehicle at the
time of the accident by "B-1" and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
CURB
SIDEWALK
PARKWAY
SIDEWALK
CURB
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to California Civil Prodecures
§1038, the City/Agency may seek to recover all costs of defense in the event an action is filed which is later
determined not to have been brought in good faith and with reasonable cause.
Signature: Date:
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