FILING A CLAIM AGAINST THE COUNTY OF MERCED



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BOARD OF SUPERVISORS CLERK OF THE BOARD James L. Brown County Executive Officer 2222 M Street Merced, CA 95340 (209) 385-7366 (209) 726-7977 Fax www.co.merced.ca.us Equal Opportunity Employer FILING A CLAIM AGAINST THE COUNTY OF MERCED Claims must be filed at the following location: County of Merced Clerk, Board of Supervisors 2222 M Street, Third Floor Merced, CA 95340 You must file your claim form, by mail or in person, with The Clerk of the Board of Supervisors, 2222 M Street, Third Floor, Merced, California 9 5340, within the time prescribed by Government Code Section 911. 2, which states: A claim r elating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented as provided in Article 2 ( commencing with Section 915) of t his chapter not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented as provided in Article 2 (commencing with Section 915) of this chapter not later than one year after the accrual of the cause of action. Any claim shall be submitted on the form provided by the Clerk of the Board of Supervisors as required by Government Code Section 910.4. The claim shall be signed by you or by some person on your behalf, and shall include all of the information required by Government Code Section 910.2.

County of Merced Self Insurance Program The County of Merced is a self-insured public entity, which operates its claims program in accordance with regulations that are set forth in the Government Code of the State of California. With self-insurance, a business pays for its losses with its own resources. Since the County is a self-insured entity, you are strongly urged to read all instructions and make yourself aware of the rules and regulations that apply to filing a claim against a public entity. If you do not comply with the filing requirements, your claim may be returned as insufficient (Government Code Section 910.8). Are you filing a Late Claim? Government Code Section 911.2 states: A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented as provided in Article 2 (commencing with Section 915) of this chapter not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented as provided in Article 2 (commencing with Section 915) of this chapter not later than one year after the accrual of the cause of action. If you are filing your tort claim after the six-month filing period, you must explain to the County your reason(s) for the delay. This is called An Application for Leave to Present a Late Claim (see Govt. Code Section 911.4). There is no application form, therefore your application should be in the form of a letter with the proposed claim attached. The County shall consider the application in accordance with Government Code Section 911.6, which lists legally acceptable reasons for filing a late claim. The County shall decide whether the application will be accepted. The County will consider the merits of the actual claim only if the Application for Leave to Present a Late Claim has been accepted. Completing the Claim Form You will need to provide the following information if you are submitting a claim to the County of Merced. Claimant s Name and Date of Birth: Full name of person claiming injury or damages and date of birth of that person. The County must know if the claim is being filed by, or on behalf of, a minor. Claimant s Address: Current address of the person claiming injury or damages. Address where notices are to be sent: The address to which correspondence pertaining to the claim will be sent, if different from #2. Phone Numbers: Provide current home and work phone numbers. If you have a mobile phone, please provide that as well. Amount of Claim: Enter the total amount of your claim as of the date of presentation of the claim, which includes the estimated amount of any prospective injury, damage, or loss, insofar as it may be known at the time of presentation of the claim. Date of Accident / Incident / Loss: The exact date of the Accident / Incident / Loss that caused your alleged damage or injury. Location of Accident / Incident / Loss: Please provide a specific location where the Accident/Loss that caused your alleged damage or injury occurred. Include as much information as you can with respect to the location. This is vital to the investigation of your claim. A diagram has been provided for your convenience.

How Did This Accident / Incident / Loss Occur? Provide a detailed account of the events that led up to your alleged damage or injury. Include all information that you believe supports your claim that the County is responsible for your alleged damage / injury. Describe Damage / Injury / Loss: Provide a detailed account of your alleged damage or injury that resulted from the Accident / Incident / Loss. Name(s) of Public Employees Causing Damage / Injury / Loss: Please list the name(s) of the County employee(s), and/or the County Department that allegedly caused your damage or injury. Names and Addresses of any and all witnesses known: Please provide the names, addresses and phone numbers of any people who witnessed the incident or occurrence causing your injury / loss / or damage. Treatment: Provide the names, addresses and phone numbers of any medical professionals who have provided the claimant with any treatment and/or care for the injury(ies) that are claimed. Itemized List of Expenses / Damages: Provide a breakdown of the amount of your total claim shown in item #5. The claimant must provide the basis of computation of the amount claimed. For property damage claims, please include one (1) estimate if the repairs are going to be under 1,000, and two (2) estimates if the repairs are going to be over 1,000. Signed By, or For, the Claimant: A claim may be presented by the Claimant, or by a person acting on his behalf. The person that presented the claim to the County for consideration should sign this form. If you are mailing your claim and would like a copy returned to you, please include a self-addressed stamped envelope. If you have any questions regarding the claims process, please contact the County of Merced Risk Management Office at (209) 385-7356. 12/11

May file in person, or mail form to: Clerk, Board of Supervisors, 2222 M Street, Third Floor, Merced, CA 95340. Print/Type Only. If you are mailing the claim and would like a copy returned to you, please include a self-addressed stamped envelope. Claims will be stamped and numbered by the Clerk of the Board of Supervisors. CLAIM AGAINST THE COUNTY OF MERCED Claim Number (Dept. Use Only) 1. Claimant s Name: Date of Birth: Last First Middle 2. Claimant s Address: Street (or P. O. Box ) City State Zip Code 3. Address where correspondence should be sent (if different from above): Name Street (or P. O. Box) City State Zip Code 4. Phone Number: ( ) ( ) ( ) Home Work Other 5. Amount of Claim: 6. Date of Accident / Incident / Loss: 7. Location of Accident / Incident / Loss: 8. Provide your description of how the Accident / Incident / Loss/ Occurred: 9. Describe Damage / Injury / Losses being claimed (including prospective damage / injury / losses to the extent it is known at the time of claim filing)

10. Name(s) of Public Entity / Employee(s) causing injury, damage, or loss: 11. Names and Addresses of any and all witnesses known: 12. If you are claiming you sustained an injury, please provide the names and addresses of any and all medical professionals who treated or are treating you for those claimed injuries. 13. Itemized list of Claimed Expenses / Damages (should equal line 5) Item: DOLLAR AMOUNT Board of Supervisors Stamp (Please attached any estimates* and/or receipts to your claim) TOTAL CLAIM Do Not Write in This Space *1 estimate if repairs are less than 1,000 *2 estimates if repairs are more than 1,000 Section 72 of the Penal Code states: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand dollars (1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, or by a fine not exceeding ten thousand dollars (10,000), or by both such imprisonment and fine. 14. Date: Signature of Claimant/Representative: You must present your claim within the time prescribed by Govt. Code Section 911.2.

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