Claim forms are unavailable on line. It is the intent of the City to know why a claim form is being requested to ensure dangerous conditions of public property is unveiled and addressed as soon as possible. Please remember, your claim is against the taxpayers of the City of Fairfield, so please be honest and respectful.
To obtain a claim form, you may contact the two Risk Management contacts above or email riskmanagement@fairfield.ca.gov. In the alternative, you may pick a claim form up in person from the City Clerk’s office on the fourth floor or the Finance Department on the first floor of City Hall.
Basic Process: To correctly process your claim, each item on the claim form is required to be completed with a few exceptions. If the question does not pertain to your claim, you may enter “NA” for not applicable.
The claim is statutorily required to be served on the City Clerk’s office on the fourth floor of City Hall. Once received, an investigation will be completed and you will be notified in writing within 45 days. If you do not receive a response by the 45th day, the claim is automatically rejected by operation of law and you may file your legal action.
Why must a Claim Be Filed? The State Legislature enacted Government Code Section 910, et al., which provides legal guidelines for resolving disputes involving public funds. The guidelines exist for both public and the public agency. Some of those guidelines are: (a) Claims for death, injury to person, or to personal property must be filed not later than six months after the occurrence. See Government Code Section 911.2; (b) Claims for damages to real property must be filed not later than one (1) year after the occurrence. See Government Code Section 911.2; and (c) A written Application for Leave to Present a Late Claim, along with a copy of the proposed claim, must be filed when a claim is not submitted within the time guideline. See Government Code Section 911.4.
Completing the Claim Form:
Please type or print clearly with a ball point pen all of the information requested. The following provides specific instructions for completing each section of the claim form.
1. Name, address and telephone numbers: - State full name, address and date of birth of the person(s) claiming the damage or injury. Please provide home and alternate telephone numbers, e-mail addresses, etc., to better enable us to contact you.
2. If there is a different address to which notices from the City are to be directed, if different from above, please note that address.
3. Date, place and circumstance of occurrence: - State the exact month, day, year and appropriate time of the incident, which caused the alleged damage/injury. State where the incident occurred and include a diagram or photos of the location of the incident. State the specific circumstances so that we will understand what happened, when it happened and where the incident occurred
4. General description of damage/injury: - Provide specific information regarding the damage or injury you are claiming. Explain why you believe the City is responsible. Include photographs and any estimate or receipts on how you calculated your loss.
5. Name(s) of public employee(s) causing injury/damage/loss, if known: - Provide name(s) of public employees.
6. Was the Police Department or other law enforcement agency contacted? If yes, please provide a police report number and name of agency.
7. Names and addresses of all witnesses, hospitals, or other individuals having knowledge relevant to the claim: Provide the names of any other individual having knowledge relevant to the claim.
8. If auto accident, please complete the following: - If you were involved in an auto accident with a City vehicle, please provide your vehicle license lumber along with the year,make and model of your vehicle as well as the City's vehicle license number (if known) and the year, make and model of the City vehicle (if known). Also, please provide a list of names, addresses and phone numbers of any passengers in vehicle at the time of the accident.
9. If amount claimed totals less or more than $10,000: - State the total amount claiming as a result of the alleged damage/injury. If damage/injury is continuing or anticipated in the future, indicate with a "+" following the dollar figure. If the total amount is unspecified or exceeds $10,000, designate the appropriate court jurisdiction for the claim.
10. Signature: The claim shall be signed by the claimant or by attorney/representative claimant. The City Clerk will not accept the claim without proper signature. Government Code 910.2 provides: "The claim shall be signed by the claimant or by some person on his or her behalf." If you are claiming personal injuries, you may be asked to later sign an authorization to release your medical records to the City.
Mail or drop off the completed and signed claim form to the City Clerk: City of Fairfield, Fourth Floor, 1000 Webster Street, Fairfield, CA 94533
