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Claim for Damage

  1. Logo - High Reso

  2. Complete if this is a Claim for Minors.

  3. CLAIM DETAILS

  4. Provide details of damage or injuries claimed.

  5. SUM YOU CLAIM ON THE ACCOUNT OF THE FOLLOWING:

  6. Provide complete details.

  7. EXPENDITURES

  8. WITNESS INFORMATION

  9. MEDICAL INFORMATION

  10. NOTE: All Claims may be required to be examined as to their claim under oath. Presentation of a false claim with intent to defraud is a felony (Cal. Pen. Code Sec. 72)

  11. Leave This Blank:

  12. This field is not part of the form submission.