CotB - Claim Against County of Nevada

These two fields are filled in by Staff
File Date

MonthDayYear
Received Date

MonthDayYear
Date
Claim Number
Claim Against County of Nevada

FOR EACH CLAIMANT, please provide the following:
Check one of the following

Claim against Nevada CountyClaim against Nevada County Sanitation District #1
Claimant Name*

First NameMiddle NameLast Name
Mailing Address*

Street Address or PO Box

Street Address Line 2

CityState

Zip Code
Phone Number
Primary
Phone Number
Alternate
Mail notices to alternate address (instead of Item #1)
2. Alternate Name

First NameMiddle NameLast Name
Alternate Mailing Address

Street Address or PO Box

Street Address Line 2

CityState

Zip Code
Phone Number
Primary
Phone Number
Alternate

3. The claim involves a vehicle
Claimant's Driver's License Number
State
Vehicle License Plate Number
State
Vehicle

YearMakeModel
Claimant's Insurance Company
Claimant's Policy Number
Was a Police report taken?
4. Date and Time Loss occurred (estimated if need be)

MonthDayYear
Date
Time MinutesAM/PM Option
5. Date Claimant first learned of loss

MonthDayYear
Manner in which Claimant first learned of loss

0/100
6. Location where loss occurred

Street Address

Street Address Line 2

CityState

Zip Code
Cross Street (if loss was the result of a vehicle accident)
Cross Street

7. Describe the circumstances of the occurrence, event, act or omission that caused the injury, damage, or loss.

0/125
Upload additional file(s) if necessary

Cancelof
8. Describe the injury, property damage, or loss so far as is known at the time of this claim. If there were no injuries, state “No injuries”.*

No injuries
0/125
9. Name and address of any other person(s) injured.

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Add a second injured person
Name and address of any other person(s) injured (2).

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Add a third injured person
Name and address of any other person(s) injured (3).

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code

10. Name and address of the owner(s) of any damaged property

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Add a second property owner
Name and address of the owner(s) of any damaged property (2)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Add a third property owner
Name and address of the owner(s) of any damaged property (2)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code

11. Name and address of all witnesses, hospitals, doctors, etc.

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Add a second Witness, etc.
Name and address of all witnesses, hospitals, doctors, etc. (2)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Add a third Witness, etc.
Name and address of all witnesses, hospitals, doctors, etc. (3)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code

12. State how or in what manner the County of Nevada or its employees were at fault, including legal basis for claim if known.

0/125
13. Name(s) of County’s employee(s) causing the injury, damage, or loss.

First NameLast Name
Name(s) of County’s employee(s) causing the injury, damage, or loss. (2)

First NameLast Name
14. Damages amount

Damages are less than $10,000Damages are equal to or greater than $10,000
Amount claimed as of this date (enter 0 if the amount is 0)
Estimated amount of any future costs (enter 0 if the amount is 0)
Total amount claimed
15. Check the appropriate box

Limited civil case ($10,000 - $25,000)Superior Court Jurisdiction ($25,001 and up)
Basis for computation of amounts claimed (attach copies of all bills, invoices, estimates, photographs, etc.)

0/70
Upload files supporting basis of computation

Bills, Invoices, Estimates, Photographs, Etc.
Cancelof
16. Any additional information that might be helpful in considering this claim

0/200

NOTE: In presenting any claim not founded upon contract, full details as to the nature of the claim, when and where it arose, the public property and officers or employees alleged to be at fault, the nature, extent and amount of the injury or damage claimed, and all other details necessary to a full consideration of the merit and legality of such claim shall be stated in writing, signed by the claimant or someone authorized by claimant. (For further particulars regarding filing of the Claim, see Section 900, et seq. of the California Government Code.)

WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM. (Penal Code Sec. 72; Insurance Code Sec. 556.1)

I have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters stated upon information or belief, and as to such matters I believe the same to be true. I declare under penalty of perjury under the laws of the State of California that the foregoing is TRUE and CORRECT.
Claimant's Signature

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