Claim Against The County Of San Diego (For Damages To Persons Or Personal Property) Page 2
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2Give a description of the property damage or loss, as is known at the time of the claim:
Give a description of the injury, as is known at the time of the claim:
Social Security Number (required for Federal reporting requirements):
Name and address of any other person injured:
Name and address of the owner of any damaged property:
Damages Claimed
Amount claimed as of this date:
$______________
Estimated amount of future costs:
$______________
Total amount claimed:
$______________
Basis for computation of amounts claimed (include copies of all bills, invoices, estimates, etc):
Damaged Vehicle (if applicable)
Make:
Model:
Year:
License Plate Number:
Mileage:
Insurance Company:
Policy Number:
Additional Information
Names and Address of witnesses, hospitals, doctors, etc:
A.
B.
C.
Any additional information that might be helpful in considering this claim:
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM (PENAL CODE § 72; INSURANCE CODE § 556.1)
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
as to those matters stated upon information or belief and as to such matters I believe the same to be true. I certify under
penalty of perjury that the foregoing is TRUE and CORRECT.
Signed this _____________ day of _______________________, 20______ at ___________________________________________
___________________________________
Claimant’s Signature
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