Office of the City Clerk Timestamp
CLAIM AGAINST THE
CITY OF CITY OF SAN JOSE, CA RECERVED
SAN JOSE (For Namaces to Persons or Personal Property) SAN JOSE CITY CLERK 2025 SEP 29 PN03:08
CAPITAL OF SILICON VALLEY CURK
daim T
Office of the City Clerk Received by:
200 East Santa Clara Street Agaist Via: U.S. Mail
Tower 14" Floor Interoffice Mail
San José, CA 95113 Over the Counter
сіУ for City use only)
Generally, a claim against the City of San José for damages to persuna ur personal property must be filed with the City Clerk of the City of San José within six months after the incident occurred. See Government Code 911.2. Completed claims must be mailed or delivered to: Office of the City Clerk, City of San José, 200 E. Santa Clara Street, Tower, 14** Floor, San José, CA 95113, telephone: (408) 535-1260. Attach copies of any receipts or other documentation to the original claim form.
TO THE CITY CLERK of the City of San José, California:
The undersigned respectfully submits the following claim and information relative to damage to persons and/or personal property:
CLAIMANT Allstate aso Sara Corona DATE OF BIRTH:n/a
ADDRESS
CLAIMAN CITY SAN JOSE STATE CA ZIP CODE 95123
HOME DRIVER'S LICENSE
PHONE I STATE AND NUMBER
SEND NOTICES REGARDING THIS CLAIM TO: (List name, mailing address and phone number if not same as above.) Allstate PO Box 660636 Dallas, TX 75266 972-915-5920 [email protected] DATE OF INCIDENT PLACE (Exact and
OR OCCURRENCE 8/7/2025 specific location 1475 Lincoln Ave
CAUSING CLAIM
CIRCUMSTANCES (Specify the occurrence, event, act, or omission which you claim caused the injury or damage for which you are submitting this claim. Where space is insufficient, attach an additional page with the claimant's name on the page.) Your driver Damon Ovalle in City of San Jose truck rear ended our insured's vehicle causing damages.
Police Report and supports attached for your review.
CITY'S ACTION (Specify action by City or its employees which caused alleged damage or injury.) Rear Ended our driver's vehicle.
CITY EMPLOYEES' NAMES OR CITY DEPARTMENT INVOLVED IN ALLEGED ACCIDENT OR INCIDENT.
Damon Ovalle
CLAIM AGAINST THE
CITY OF SAN JOSE, CA
DESCRIPTION OF LOSS (Describe injury, property damage or loss, so far as is known at this time. If there were no injuries, state "NO INJURIES.")
Itemized Estimate and supports attached.
OTHER INJURED PERSONS (list names and addresses)
OWNER OF PROPERTY DAMAGED (if different from claimant)
AMOUNT CLAIMED:
Amount claimed as of this date: $
Estimated amount of future costs: $
Total amount claimed: $24,109.23
Basis for computation of amounts claimed (include copies of bills, invoices, estimates, etc.):
Itemized Estimate and supports attached.
WITNESSES, HOSPITALS, DOCTORS, ETC. (list names and addresses):
ADDITIONAL INFORMATION (List any additional information that might be helpful in considering your claim.):
WARNING! IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM (Penal Code Section 72) 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 to those matters stated upon information or belief and as to such matters I believe the same to be true. İ certify under penalty of perjury that the foregoing is TRUE and CORRECT.
18 day of _ Sept -. 20 25
Signed this
Claimant's Signature
Revised 10/1/2015