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City of Los Angeles Claims for Damages Form

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CLAIM FOR DAMAGES
TO PERSON OR PROPERTY

OFFICE OF THE CITY CLERK
City of Los Angeles

Please mail the original signed form to (copies and faxes not accepted):

Address: Office of the City Clerk
200 North Spring Street
Room 395, City Hall
Los Angeles, CA 90012

Hours: 8:00 am to 4:30 pm, Monday – Friday

Phone: (213) 978-1133

You may also bring the form to our Public Counter at the above address during regular business hours.

Reminder: Please make a copy for your own records.

INSTRUCTIONS

1. Claims for death, injury to person or to personal property must be filed not later than six months after the occurrence. (Gov. Code Sec. 911.2).

2. Claims for damages relating to any other type of occurrence must be filed not later than one year after the occurrence. (Gov. Code Sec. 911.2).

3. Read entire claim before filing. Claim can be mailed or filed in person. No faxes accepted.

4. See Page 3 for diagram upon which to locate place of accident.

5. This claim form must be signed on Page 3 at bottom.

6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.

7. Fill out in duplicate. ONE COPY TO BE RETAINED BY CLAIMANT.

8. Claim must be filed with CITY CLERK, (Gov. Code Sec. 915A) 200 NORTH SPRING STREET, ROOM 395, CITY HALL, LOS ANGELES, CA 90012

TO: CITY OF LOS ANGELES

CLAIM NO.

RESERVE FOR FILING STAMP

CLAIM NO.

Name of Claimant

Age of Claimant

Home address of Claimant

City, State and Zip Code

Home Telephone Number

Business address of Claimant

City, State and Zip Code

Business Telephone Number

Give address to which you desire notices or communications to be sent regarding this claim:

How did DAMAGE or INJURY occur? Please include as much detail as possible.

When did DAMAGE or INJURY occur? Please include the date and time of the damage or injury.

Where did DAMAGE or INJURY occur? Please describe fully, and locate on the diagram on the reverse side of this sheet.

Where appropriate, please give street names and addresses or measurements from specific landmarks:

What particular ACT or OMISSION do you claim caused the injury or damage? Please give names of City employees causing the injury or damage and identify any vehicles involved by license plate number, if known.

Please list names and address of Witnesses, Doctors and Hospitals:

PAGE 2 - SEE PAGE 3 THIS CLAIM MUST BE SIGNED AT BOTTOM

What DAMAGE or INJURIES do you claim resulted? Please give full extent of injuries or damages claimed:

What is the AMOUNT of your claim? Please itemize your damages:

If you have received any insurance payments, please give the names of the insurance companies:

For all accident claims please place on the following diagram the names of the streets where the accident occurred and the nearest cross-streets; indicate the place of the accident by an "X" and by showing the nearest address and distances to street corners. Please indicate where North is on the diagram.

Note: if the diagram does not fit the situation, please attach your own diagram.

Diagram area for accident location / street layout

Signature of Claimant or person filing on claimant's behalf giving relationship to claimant:

Print Name:

Date:

PAGE 2

PAGE 3

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What the City of Los Angeles Claims for Damages Form Is

The City of Los Angeles Claims for Damages Form is the formal written document you submit to notify city officials and begin a claim for injury, property loss, or other damages allegedly caused by the City or its employees. The form captures claimant identity, incident details, the nature and amount of damages claimed, and any supporting evidence. Submitting the form is typically a prerequisite to filing suit against the municipality; it opens an administrative review and creates the official record used by city counsel and investigators.

Why this form matters for timely, documented claims

Filing the City of Los Angeles Claims for Damages Form documents your claim, triggers the city’s administrative review, and preserves the ability to pursue litigation if necessary. Accurate, complete presentation increases the chance of early resolution and avoids procedural bars that can otherwise prevent recovery.

Why this form matters for timely, documented claims

Who completes and relies on this form

Use the form early in the process and consult counsel when complex damages, multiple parties, or legal deadlines are at issue.

  • Private individuals who suffered personal injury, property damage, or economic loss from city operations or facilities.
  • Business owners or vendors claiming lost revenue, damaged equipment, or contract-related losses tied to city actions.
  • Legal representatives, guardians, or insurance adjusters filing on behalf of claimants or subrogated interests.

Key parts of a professional claims submission

A well-prepared Claim for Damages includes structured claimant details, a factual incident narrative, clear damage quantification, evidence attachments, attestations, and a signed authorization to verify identity and serve notices.

Claimant Details

Full legal name, business name if applicable, mailing address, daytime phone, and email for official notices and correspondence.

Incident Information

Exact date, approximate time, and precise location of the event. Include identifiers such as street intersections, facility names, or permit numbers where known.

Narrative

Concise, factual description of what occurred, who was present, and how city action or omission caused the loss; avoid conjecture and opinion.

Damages Claimed

Itemized amounts for property repair, medical costs, lost income, and other economic losses; supporting invoices or estimates should be attached.

Supporting Evidence

Attach photos, police reports, invoices, medical records, witness statements, and any permit or contract documents that corroborate your claim.

Signature & Attestation

Claimant or authorized representative signs and dates the form under penalty of perjury or false statement provisions where indicated.

Required fields at a glance

Claimant Name: Full legal name
Contact Information: Address, phone, email
Incident Date: MM/DD/YYYY
Incident Location: Street, city detail
Description: Brief factual summary
Amount Claimed: Itemized total

Consequences of incomplete or late submissions

Missed Deadline: Claim may be barred
Incorrect Information: May delay or invalidate claim
Insufficient Evidence: Higher likelihood of denial
Unauthorized Signer: Signature may be rejected
Missing Attachments: Investigation pauses
False Statements: Civil or criminal penalties

Common preparation pitfalls to avoid

  • Submitting vague narratives that omit the specific sequence of events and the causal link to city action or inaction.
  • Failing to attach invoices, estimates, medical records, or photos that substantiate the amount claimed and the nature of loss.
  • Using inconsistent names, addresses, or dates across forms and supporting documents, which can complicate identity verification.
  • Overlooking signature requirements, witness lines, or notarial blocks required for certain claim submissions or representative filings.

Step-by-step: completing the form accurately

Follow these sequential tasks to prepare a complete, legible, and verifiable claim submission to the City of Los Angeles.

  • 01
    Gather Documentation: Collect photos, invoices, reports, and witness contacts.
  • 02
    Complete Fields: Enter claimant details, incident facts, and amounts.
  • 03
    Attach Evidence: Upload or staple supporting documents to the form.
  • 04
    Sign and Submit: Sign, date, and deliver to the designated city office.

What happens after you submit a claim

Submission starts administrative review; the city logs the claim, investigates, and issues a decision or settlement offer within its internal timelines.

  • Acknowledgment: City acknowledges receipt and assigns a claim number.
  • Investigation: City departments review facts and supporting records.
  • Determination: City counsel issues acceptance, denial, or counteroffer.
  • Appeal/Litigation: If denied, claimant evaluates statutory remedies.

Download, sign, and archive options

You can prepare the form in paper or digital formats; choose a workflow that preserves the signed original and supporting attachments for future reference.

File Formats

PDF is preferred for distribution; preserve an editable DOCX copy for internal drafting and redaction before finalizing.

eSigning

Electronic signatures are widely accepted under ESIGN and UETA when intent, attribution, consent, and retention are satisfied.

Notarization

Not all city claim forms require notarization, but some representative filings or affidavits may need notarized signatures or witnesses.

Records Retention

Keep a certified copy of the submitted claim and all exhibits; city responses should be retained with your case file.

Practical tips for accurate and efficient claims

Small adjustments in preparation increase clarity and reduce processing delays.

Be precise with dates and locations
List the exact date, time, and street address or facility name to help investigators locate incident records and surveillance footage.
Itemize damages clearly
Provide line-item costs and attach invoices or estimates so the city can evaluate economic loss without repeated follow-up.
Provide witness information
Include full names, contact details, and brief witness statements when available to support factual assertions.
Keep a submission log
Record delivery method, recipient, claim number, and date received to maintain evidence of timely presentation and communication history.

Processing timelines and what to expect

Actual timing varies by case complexity, but the city follows a sequence of administrative steps from receipt to final disposition.

Acknowledgment timeline:

City typically acknowledges receipt within 30 days of submission.

Initial review window:

Administrative screening and basic validation often occur within 30 to 60 days.

Investigation period:

Detailed review by departments may take 60 to 120 days depending on complexity.

Decision or offer:

A disposition, settlement offer, or denial is commonly issued within 90 to 180 days.

Further remedies:

If denied, statutory limitations and filing deadlines for court action still apply and vary by claim type.

How to set up an online submission workflow

Configure a digital workflow to reduce errors and collect all required data and evidence before final submission.

Field Configuration
Document Upload Require PDF or JPG attachments for evidence
Signer Assignment Designate claimant and authorized representative roles
Authentication Use email verification or SMS code
Retention Policy Set storage to retain originals for minimum period

Digital submission and platform compatibility

Use platforms that capture timestamps, IP addresses, and an audit trail to document the signing and submission chain of custody.

  • Supported Files: PDF, DOCX, JPG accepted
  • Integrations: Works with CRM and cloud storage
  • Authentication: Email, SMS, or stronger methods

eSignature vendor comparison for claims workflows

Compare baseline pricing and core capabilities when selecting an eSignature provider to manage claim forms and supporting attachments.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial, no credit card required Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about filing a City of Los Angeles claim

Answers to common questions about form submission, signatures, evidence, and next steps when the city responds.


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