Claim Instructions and Information

Transcription

1 CIVIL DIVISION Columbus, Ohio Fax: CLAIMS DIVISION Columbus, Ohio Fax: RICHARD C. PFEIFFER, JR. CITY ATTORNEY COLUMBUS, OHIO Claim Instructions and Information PROSECUTOR DIVISION 375 S. High Street Columbus, Ohio Fax: REAL ESTATE DIVISION Columbus, Ohio Fax: Please find enclosed the City of Columbus Claim form. Please complete the form, sign in front of a notary and return the form to the proper department. It is important to note that the City will not open a claim and an investigation will not begin until a completed claim form is received. If a portion of the form does not apply to your particular situation, please write not applicable or n/a. All details, dates, times and location provided must be accurate. If you are not sure whether the City is liable for your injury or damage, please submit your claim to the City Department in question and the Department will contact you. Generally, the City of Columbus is not liable in damages in a civil action for injury, death, or loss to person or property allegedly caused by any act or omission of the City or its employees. There are some exceptions. The City may be liable for: (1) the negligent operation of a motor vehicle, unless police, fire or EMS are responding to an emergency; (2) the negligent performance of proprietary functions; (3) the negligent failure to keep public roads in repair and negligent failure to remove obstructions; (4) the negligence of its employees within or on the grounds of, and due to physical defects within or on the grounds of, buildings; or (5) when the Ohio Revised Code imposes liability. If one of these exceptions applies, you must file a claim with your insurance company first. The Ohio Revised Code limits the amount of money a city may pay. Any amount of money you received, or should receive even if you haven t, is deducted from the amount owed to you by the city. The City would then be responsible for such items as your deductible. Ohio Revised Code, , states that no insurer or other person is entitled to bring an action under a subrogation provision of insurance or other contract against a political subdivision with respect to those benefits. Attachment Checklist-Please read before submitting your claim. This information is necessary in order to open a proper investigation. All of the above information is necessary to start the investigation. Liability cannot be determined until a thorough investigation of your claim is completed. If claiming vehicle damage, you need to provide: Declaration Page of car insurance policy showing deductible, copy of title, registration or lease contract, two written estimates, police report (if applicable), current mileage and photographs of vehicle damage. If you are claiming tire damage, the age of the tire is required. If claiming personal injury: Copies of all medical reports including doctor bills, hospital bills and pharmacy receipts If claiming other property damage: A copy of the homeowner s insurance policy that includes the deductible amount is required. A separate itemized list of property damages with a description of each item, serial number, quantity lost, Revised 03/15/2016 1

2 purchase date or age and purchase price, bills, receipts and estimates. If the damage was to a business you must submit proof of business ownership and/or lease rights and responsibilities. Once you have collected all of the required information and completed the claimant statement form, please forward the information to the appropriate Department to begin the investigation process. If the City is liable, the City will issue you a check. This process may take 4 to 6 weeks. You will be asked to sign a Release and Agreement and a W-9 form, and return them to the City Department that is handling your claim. Building & Zoning Services Development Housing, Building & Code Enforcement Fire Police/ Impound Lot Pot Holes, Refuse, Transportation, Streets, Signs, Construction Recreation and Parks Water, Power, Sewers and Drains 757 Carolyn Avenue Columbus, Ohio W. Gay Street 3 rd Floor 3675 Parsons Avenue Columbus, OH Contact by phone first 50 W. Gay Street Columbus, Ohio E. Broad Street Columbus, OH Dublin Road Linda Guyton lkguyton@columbus.gov Chris Swauger ciswauger@columbus.gov Scott Marburger smmarburger@columbus.gov Nicole Mullane nmmullane@columbus.gov Call Center You must contact the 311 call center & place a service claim. A Claim Investigator will contact you after the service claim is received Connie Warner cgwarner@columbus.gov Angie Courtright Shelly Seniuk amcourtright@columbus.gov slseniuk@columbus.gov Potholes With respect to any damage your vehicle may have sustained, we must inform you that the City, by statute, has certain immunities from liability for damages of this nature. As stated above, Ohio Revised Code Section addresses these immunities. In general, in order to recover in a suit involving damage proximately caused by roadway conditions, including potholes, the party claiming damage must prove that either: 1) the City had actual or constructive notice of the pothole and failed to respond in a reasonable amount of time, or responded in a negligent manner, or 2) that the City, in a general sense, maintains its roadways negligently. Hopefully, this has answered all of your questions; however, if you still need assistance, you can contact the City Department that will handle your claim or the City Attorney s office and speak to one of the individuals listed below. Katie Aukerman Legal Investigator (614) or ksaukerman@columbus.gov Nicole Mullane Legal Investigator (614) or nmmullane@columbus.gov If it is after normal working hours you may contact the Call (614) or go to The call center hours are Monday Friday 7:00am to 6:00pm. If this is an emergency please dial to contact the police. Revised 03/15/2016 2

3 City of Columbus Hours of Operation: 8am to 5pm Weekdays NAME BIRTH DATE HOME PHONE WORK PHONE STREET ADDRESS CITY STATE ZIP ADDRESS EMPLOYER NAME CITY DEPARTMENT THAT WAS INVOLVED: NAME OF EMPLOYEE (IF KNOWN): TYPE OF DAMAGE: VEHICLE OTHER PROPERTY IF YES, WHAT POLICE DEPT. & REPORT #? IF NO, WHY? INJURY POLICE REPORT MADE? YES NO YES N INCIDENT DATE INCIDENT TIME ADDRESS OF INCIDENT DETAILED DESCRIPTION OF INCIDENT WITNESS NAME: WITNESS NAME: PHONE: PHONE: ADDRESS: ADDRESS: FOR VEHICLE DAMAGE CLAIMS OR AUTOMOBILE ACCIDENTS VEHICLE MAKE/MODEL YEAR LICENSE PLATE # MILEAGE OWNER'S NAME DRIVER'S NAME OWNER'S ADDRESS & PHONE DRIVER'S ADDRESS & PHONE TWO REPAIR ESTIMATES (ATTACH ESTIMATE DOCUMENTS) (1) $ (2) $ # OF PEOPLE IN YOUR VEHICLE: WHO: DEDUCTIBLE AMOUNT AUTO INSURANCE COMPANY MEDICAL INSURANCE COMPANY FOR DAMAGE CLAIMS OTHER THAN VEHICLE DAMAGE WHAT IS DAMAGED CAUSE OF DAMAGE & HOW IT WAS DAMAGED AGE OF DAMAGED PROPERTY: PROPERTY INSURANCE COMPANY REPLACEMENT, RESTORATION OR REPAIR COST (IF MORE THAN ONE ITEM, YOU MUST FILL OUT THE ITEMIZED PROPERTY CLAIM FORM): DEDUCTIBLE AMOUNT Claim Form Rev Page 1

4 City of Columbus FOR PERSONAL INJURY CLAIMS NATURE & EXTENT OF YOUR INJURY HEALTH INSURANCE COMPANY DEDUCTIBLE AMOUNT HOSPITAL TRANSPORTED TO: ATTENDING PHYSICIAN NAME ATTENDING PHYSICIAN ADDRESS TOTAL MEDICAL EXPENSES TO DATE AMOUNT PAID BY INSURANCE AMOUNT PAID OUT OF POCKET LIST & PROVIDE PROOF OF ANY PHYSICAL DISABILITIES PROVIDE DATE AND NATURE OF ANY PRIOR INJURIES The Ohio Revised Code, Section outlines limitations of damages awarded for claims against political subdivisions. If a claimant receives or is entitled to receive benefits from insurance policy or policies, that amount will be deducted from any award the polictial subdivision may condider paying. This includes Medicaid, Medicare and auto policies. You must file a claim with your insurance company prior to filing a claim with the City of Columbus. I further state that I am not entitiled to receive additional reimbursement for these injuries and/or damages from any other source other than the City of Columbus and that the claim(s) arising from these injuries and/or damages are a direct result of this incident. CLAIMANTS SIGNATURE DATE SWORN TO BEFORE ME and subscribed in my presence this day of, 20. NOTARY PUBLIC, STATE OF OHIO Claim Form Rev Page 2

5 Property Description (Including brand name and serial #) City of Columbus Itemized Property Claim Form Quantity Date purchased or Age Purchase Price Replacement, Restoration or Repair cost Claim Form Rev Page 3