Mail Claim Form To:
City of Lake Elsinore City Clerk
Claim for Damage or Injury City of Lake Elsinore
130 South Main Street
Use Black or Blue Ink Type Lake Elsinore, California 92530 Attach Additional Pages if Necessary FEB CEIVEI
CLAIMANT, NOTIFICATION AND GENERAL INFORMATION 15
CLAIMANT ADDRESS (Required)
CLAIMANT FULL NAME 32989 Macy st, Lake Elsinose, CA CITY CLERK'S OFFICE 2026 Nitin Jindal NOTIFICATION ADDRESS (IF DIFFERENT THAN ABOVE) PERSON TO BE NOTIFIED OF ANY ACTION TAKEN ON CLAIM 16581 45 Ranch Pkwy, San Diego, CA 92127 Nitin Jindal
MEDICARE BENEFICIARY PHONE NUMBERS)
CLAIMANT DATE OF BIRTH
562965 5333
Yes No
09/20/74
ACCIDENT TIME AM / PM EMAIL ADDRES (OPTIONAL)
DATE OF ACCIDENT jindal-nitin @hotmail.um
PLACE OF ACCIDENT (COMPLETE ADDRESS AND DESCRIPTION TO LOCATE ON A MAP / OR VISIT THE SCENE): 10/18/23
PROPERTY DAMAGE
DESCRIBE PROPERTY DAMAGE CLAIMED, INCLUDING LOCATION, NATURE OF DAMAGE, CAUSE AND HOW VALUE IS CALCULATED: Because of theis actions our restintion wask was stopped, do osder. We have iost
an sent refuse to give witten sTor
PERSONAL INJURY
STATE THE NATURE AND EXTENT OF CLAMANS COASTE AS THA till now $60,000 We are subbering financial damajes
halbeen
oooth of in come
LIABILITY
INDICATE HOW THE ACCIDENT HAPPENED, WHY YOU FEEL THE CITY IS LIABLE AND NAME OF INVOLVED CITY EMPLOYEES):
AMOUNT OF CLAIM
PERSOAN INJURY S: TOTAL AMOUNT OF CLAIM:
PROPERTY DAMAGE: $ 60,000
$60,000
WITNESSES
NAME (S) / ADDRESS(ES):
DECALRE UNDER THE PENALTIES OF PURJURY OF THE STATE OF CALIFORNIA THAT TH OREGOING IS CORRECT AND THAT THE AMOUNT OF THIS CLAIM COVERS ONLY DAMAGES AN
CRIMINAL PENALTY FOR
PRESENTING FRAUDULENT CLAIM INJURIES CAUSED BY THE ACCIDENT DESCRIBED HEREIN.
OR MAKING FALSE STATEMENTS 02/04/24
DATE
Totomy. (Seo Calfornia Panal Cot a SIGNATURE OF CLAIMANT 572)
NOTICE TO CLAIMANT
order for your claim to receive proper consideration you are requested to supply the informalion called for on this application form. A aterial facts should be stated on this form, as it will be the basis of further action upon your claim. The instructions set forth should t read carefully before the form is compicted.
INSTRUCTIONS
Honored See Govement Code 3910 2, the amount aimed the be sustaine by compete lone ad leaf can bad.
Whether attached to the claim form, or submitted subsequently, evidence supporting the amount claimed may include:
(a) In support of a claim for the personal injury or death, the claimant should submit documentation evidencing the injuries sustained, treatment rendered, the period of hospitalization, future treatment, the degrees of permanent disability, the prognosis, and vidence of medical bills received and paid. It is recommended that such medical evidence NOT be attached to the claim for, bu hat such substantiation of damages be provided upon request. The Claim Form and attachments thereto is a public record and subject to public inspection.
b) In support of claims for damage to property which has been or can be economically repaired, submit at least two itemized signe pair estimates or statements of damage by reliable, disinterested persons, or if payment has been made, the itemized signe receipts evidencing payment.
(c) In support of claim for lost property or property that cannol be economically repaired, submit documentation of the original cost o he property, the date of purchase, and the value of the property before and after the accident. The statements demonstrating th alue of the property should be disinterested competent persons, preferably reputable dealers, persons familiar with the type ‹ operty, by two or more competitive bidders, or advertisements for the same or similar propert e completed Claim Form must be mailed or delivered to the City Clerk at the address on the prior page. Questions or requests rther information should be directed to the City Clerk's Office at (951) 674-312
INSTRUCTIONS REGARDING INSURANCE COVERAGE
i order that claims may be properly adjusted by the City or your insurance company, it is essential that the claimant provide t llowing information regarding any insurance coverage available for the loss or injur DO YOU CARRY AUTO COLLISION COVERAGET IF YES" GIVE NAME AND ADDRESS OF INSURANCE COMPANY AND POLICY NUMBER:
• Yes 7f No
VE YOU FILED A CLAIM WITH YO IF "YES" WHAT IS YOUR DEDUCTABLE? INSURANCE COMPANY CLAIM NO.?
SURANCE CARRIER IN THIS INSTANC
• Yes ฿ No
REFERENCE TO YOU CLARA VHATACTION HAS YOUR INSURER TAKEN, OR WHAT ACTION DOES IT PURPOSE TO TAKE WITH THE DO YOU CARRY PUBLIC LIABILITY AND PROPERT IF "YES" GIVE NAME OF INSURANCE CARRIER:
DAMAGE COVERAGE:
NO.
NAME OF CLAIMANT:
NITIN JINDAL