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Filled By City Clerk

Date Received*field type date
Mailed Claims Damage Form*field type file upload
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INSTRUCTIONS

Before you File a claim

If your claim involves damages related to your sewer or water line, please contact Long Beach Water Department to discuss Homeowner vs City responsibilities. For more info, please visit Long Beach Water Department.
If your claim involves Tree Maintenance/Request Removal, please visit Public Works-Street Trees for additional information on the City’s Tree Maintenance Policy.

Filing a Claim

Pursuant to the California Government Claims Act (Government Code sections 810-996.6), in most cases a claim must be filed if you are seeking money damages from the City and/or one of its employees. With very limited exceptions, no lawsuit for money damages may be brought against the City or its employees unless a written claim has been properly filed with the City.
Claims for death, injury to person or to personal property must be filed no longer than six (6) months after the date of occurrence (Government Code Section 911.2).

Any other claim, including, but not limited to, claims for damages to real property, must be filed no later than one (1) year after the occurrence (Government Code Section 911.2(a)).

WARNING: THIS IS NOT INTENDED AS LEGAL ADVICE. YOU SHOULD CONSULT WITH AN ATTORNEY TO DETERMINE THE TIME PERIOD FOR FILING EITHER A CLAIM OR A LAWSUIT.
Our Claims Process

Once your claim is delivered to the City Clerk’s Office, the claim will be transferred to the Office of The City Attorney for handling. The claim will be assigned to a Liability Claims Adjuster to conduct an investigation of liability. You will be contacted by a Liability Claims Adjuster to acknowledge receipt of your claim. The Adjuster will be able to answer any questions you may have regarding the claims process.

Every claim is investigated to determine:
- How the loss/incident occurred
- If the City and/or its employees are liable
- The extent of damages, if any
- Whether your claim is recognized under the law, and if so, what the law considers fair compensation
Our claims process includes, but is not limited to, taking statements from any parties involved, interviewing witnesses and/or employees, gathering and reviewing all related reports and documents.

We may contact you during our claims process to obtain additional information to ensure a thorough claims investigation.

Every claim will be investigated and a decision will be made with regard to what action should be taken. However, your attention is directed to Government Code Section 912.4 which provides, in part, that a claim is deemed rejected if no action is taken within 45 days after filing.

A written notice of denial or acceptance will be mailed to you upon finalizing the claim.

Please note: Claims accepted for damages to a vehicle will be settled with legal owner, representing attorney or insurance carrier (provided proof of right to recovery).
Denied Claims
Each claim is reviewed thoroughly. If your claim is denied, we will explain the reasons for the denial. Should you disagree with the claims denial, you have the right to file a civil action, including a small claims action. However, subject to certain exceptions, you have only six (6) months from the date that the notice of denial was personally delivered or deposited in the mail to file a court action on your claim. See Government Code § 945.6.

AGAIN, YOU SHOULD CONSULT WITH A LAWYER IF YOU HAVE ANY SPECIFIC QUESTIONS AS TO WHEN YOU MUST FILE A LAWSUIT AFTER YOUR CLAIM IS DENIED. IF YOU PLAN TO FILE A LAWSUIT, YOU SHOULD NOT DELAY SEEKING ADVICE.

This time limitation applies only to causes of action for which Government Code §§ 900 - 915.4 required you to present a claim. Other Causes of action, including those arising under federal law, may have different time limitations.

Claimant Information

Name of Claimant*field type single line
Input blocked. Maximum character limit of 200 characters reached.
Telephone #*field type single line
Input blocked. Maximum character limit of 40 characters reached.
Driver License #field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Date of Birthfield type date
Home Address of Claimant*field type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country

Communication Information

Information of individual to which notices or communication are to be sent to regarding this claim

Same as Claimant Information?*field type radio button
Same as Claimant Information?YesNo
Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Phone Number*field type single line
Input blocked. Maximum character limit of 40 characters reached.
Emailfield type email
This email will be used for notification purposes
Address*field type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country

Claim Information

Is Claim Related to a Vehicle?field type radio button
Is Claim Related to a Vehicle?YesNo

Vehicle Information

Makefield type single line
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Modelfield type single line
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License Plate #field type single line
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Vehicle Colorfield type single line
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Date and Time of Incident*field type date
Exact Location of Occurrence*field type single line
(Be descriptive. Include address and landmarks. Example: 411 W Ocean Blvd, Long Beach, CA 90802 In front of the Long Beach sign)
Input blocked. Maximum character limit of 4000 characters reached.
Claim is Forfield type checkbox
Claim is ForDeath/InjuryPersonal PropertyReal PropertyOther (explain):
Is the claimed amount less than $10,000?*field type radio button
Is the claimed amount less than $10,000?YesNo
What is the claimed amount?*field type currency
$(include estimated amount of any prospective injury or damage)
What is the basis for your computation of the amount claimed?*field type single line
(Be specific. List bills/payments, estimates etc.)
Input blocked. Maximum character limit of 4000 characters reached.
If the claimed amount exceeds $10,000, would the claim be a limited civil case?*field type radio button
If the claimed amount exceeds $10,000, would the claim be a limited civil case?YesNo
What happened?*field type multi line
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Why is the city of Long Beach responsible?*field type multi line
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Were the police at scene?field type radio button
Were the police at scene?YesNo
Police report numberfield type single line
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Names and Phone Numbers of Witnessesfield type multi line
City of Long Beach Department Involvedfield type single line
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Name of Public Employee Involvedfield type single line
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Was a city vehicle involved?field type radio button
Was a city vehicle involved?YesNo
License number of city vehiclefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Make/Model of city vehiclefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Has this claim been reported to an Insurance Companyfield type radio button
Has this claim been reported to an Insurance CompanyYesNo
Insurance Company Namefield type single line
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Claim Numberfield type single line
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Claims Representative's Namefield type single line
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Phone Numberfield type single line
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Additional information related to claimfield type multi line

Supporting Documents

Along with completing the Claim Form, please attach supporting documentation. Documentation may include, but is not limited to:

Property Damage Claims

• repair estimates, invoices, proof of payments, photos of damage

Personal Injury Claims

• medical records, itemized billing, proof of payments

To help ensure a smooth process of your claim, we highly recommend that you minimize your loss and damages. Also make sure that expenses incurred are not accumulating unnecessarily.

Please disclose whether this loss has been claimed with another entity such as an insurance carrier. If so, please include name of company, handling claims representative and claim number on your claims form.

If you file a claim with your insurance company, they may decide to file a claim against the City to recover monies paid. You may file a claim against the City for reimbursement of the applicable deductible and/or your out of pocket expenses.
Supporting Documentsfield type file upload
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Signature

I certify under penalty of perjury that the foregoing is true and correct
(Signed)*field type signature
I certify under penalty of perjury that the foregoing is true and correct
IF MINOR (UNDER 18) PARENT OR GUARDIAN MUST SIGN FORM.
City*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Datefield type date
Date will be captured on form submission
Note: Presentation of a false claim is a felony (Cal. Pen. Code Sec 72)

Hidden Processing Section

Current Userfield type single line
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Initiatorfield type single line
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Claims for Damages

INSTRUCTIONS

Before you File a claim

Filing a Claim

Our Claims Process

Denied Claims

Claimant Information

Communication Information

Claim Information

Supporting Documents

Property Damage Claims

Personal Injury Claims

Signature