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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION

CLAIM AGAINST DEPARTMENT OF TRANSPORTATION FOR AMOUNTS $5,000 OR LESS
LD-0274 (REV. 7/2010)
PERSONAL INFORMATION NOTICE
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code Sections 1798, et seq.), notice is hereby given for the request of
personal information by this form. The requested information is voluntary. The principal purpose of the voluntary information is to facilitate the processing of this form. The
failure to provide all or any part of the requested information may delay processing of this form. No disclosure of personal information will be made unless permissible under
Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper identification, to inspect all personal information in any record maintained
on the individual by an identifying particular. Direct any inquiries on information maintenance to your IPA Officer.
This form is to be used when filing a claim against the Department of Transportation as provided in Government Code Section 935.7

PLEASE: Print or use a typewriter when filling out form.

WARNING: GOVERNMENT CODE § 911.2
Sign and date claim form. PROVIDES SIX MONTHS FROM THE DATE OF
(UNSIGNED AND UNDATED FORMS WILL NOT BE ACCEPTED) INCIDENT TO FILE A CLAIM FOR PERSONAL
INJURY OR PROPERTY DAMAGE.
STATE USE ONLY
1. NAME: LAST FIRST MIDDLE FILE NUMBER

HOME ADDRESS BUSINESS PHONE HOME PHONE

CITY STATE ZIP CODE

2. PUT A SPECIFIC TIME AND DATE WHEN THE DAMAGE FIRST OCCURED TIME OF INCIDENT AM DATE OF INCIDENT
PM
3. STATE THE LOCATION OF THE INCIDENT WITHIN ONE-HALF MILE (CITY, COUNTY, HIGHWAY, NEAREST OFF-RAMP, CROSS STREET, OR
POSTMILE).

4. EXPLAIN HOW THE INJURY OR DAMAGE OCCURRED

5. WHAT DO YOU CLAIM CALTRANS OR ITS CONTRACTOR DID TO CAUSE YOUR INJURY OR DAMAGE?

6. WHAT INJURY OR DAMAGE ARE YOU CLAIMING HAPPENED?

7. WHAT IS THE DOLLAR AMOUNT OF YOUR CLAIM FOR DAMAGES? (SUBMIT TWO ESTIMATES OR PAID RECEIPTS)
$
NAME OF INSURER
8. INSURANCE INFORMATION IS REQUIRED

HAVE YOU SUBMITTED A CLAIM TO

YOUR INSURANCE CARRIER? YES NO

IF YES, WERE YOU PAID? YES NO FOR WHAT AMOUNT?

$

9. ARE YOU THE REGISTERED OWNER? YES NO

MAKE OF VEHICLE MODEL COLOR YEAR VEHICLE LICENSE NO.

I HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE FOREGOING FACTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

DATE
10.SIGNATURE OF CLAIMANT

REVERSE SIDE FOR STATE USE AND FILING INFORMATION ON CLAIMS

STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CLAIM AGAINST DEPARTMENT OF TRANSPORTATION FOR AMOUNTS $5,000 OR LESS
LD-0274 (REV. 7/2010)

FOR STATE USE ONLY (BELOW)

DATE CLAIM RECEIVED APPROVED
REVIEWED BY: DISTRICT CLAIMS OFFICER
AMOUNT $
TORT FUND/ CONTRACTOR
STATE RESPONSIBILITY CONTRACT CONTINGENCY RESPONSIBILITY DENIED

LOCATION CODING
DISTRICT COUNTY ROUTE POST MILE

COST CODING

DEPARTMENT FUND UNIT OBJECT PROJECT NUMBER PHASE

ITEM CHAPTER STATUTES FISCAL YEAR SCHEDULE NUMBER

I hereby certify upon my own personal knowledge that the budgeted funds are ACCOUNTING OFFICER SIGNATURE DATE
available for the period and purpose of the expenditure stated above.

FOR CLAIMS FIVE THOUSAND DOLLARS ($5,000) OR LESS

Select District Address CLAIMS OFFICER

Department of Transportation

FOR CLAIMS OVER FIVE THOUSAND DOLLARS ($5,000)

You must file with the Victim Compensation and Government Claims Board in Sacramento,
California. If you have any questions about claims of more than five thousand dollars, call or write:

Victim Compensation and Government Claims Board

POST OFFICE BOX 3035
SACRAMENTO, CA 95812-3035
PHONE: 1-800-955-0045
http://www.vcgcb.ca.gov/claims/default.aspx

The fact that this statement of the procedure to be followed in asserting a claim against the State of California has been
furnished to you or that an investigation of any claim is undertaken is not to be taken as an admission of liability in any
respect on the part of its officers or employees; nor is the fact that this additional statement has been furnished to you to be
construed as a waiver of any requirements imposed by law, or any defense which may be available to the State of
California in connection with any claim that might be filed against it.

For individuals with sensory disabilities, this document is available in alternate formats. For information call (916) 654-6410 or TDD (916) 654-3880 or write Records
ADA Notice and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
 INSTRUCTIONS FOR FORM LD-0274

Please note that failure to complete all sections of the claim form may delay
the processing of your claim or result in the return of your claim.

1. Claimant's Name and Contact Information: State the full name, mailing address, and telephone number(s) of the person or
entity claiming property damage or loss.

2. Date and Time When the Damage First Occurred: State the exact month, day, year, and time of the incident giving rise to
the claim.

3. Location of Incident: Specify the city and/or county, highway #, direction of travel, nearest exit(s), cross-streets, and any
additional information indicating where the accident occurred. Providing a map is optional, but advised. The more information
you provide, the easier it is for us to assist you! You can also attach a copy of the police report of the accident to help show
the location.

4. How Your Damage Occurred: Provide complete details about what happened to cause your damages.

5. What Do You Claim Caltrans or Its Contractor Did to Cause Your Injury or Damage? State in detail all facts in support of
your claim. Include all persons or entities involved and why you believe Caltrans or its contractor is liable. If applicable,
provide the name of the Caltrans employee or state vehicle license plate/ID number.

6. What Injury or Damage Are You Claiming Happened? Specify the exact injury or damage for which you are claiming,
including all alleged injuries, property damage, and/or loss.You can attach photographs and any additional supporting
documents.

7. What Is the Dollar Amount of Your Claim for Damages? State the total dollar amount for which you are claiming. The State
of California requires (2) estimates and/or (1) paid receipt for all damages claimed. It you are submitting proof of payment,
copies of credit card statements or copies of the front and back of cancelled checks are required. Invoices will not be accepted
as actual proof of payment. All invoices must list the claimant's name and vehicle license plate number, vendor's letterhead,
and an itemized list of repairs. Caltrans will not accept quotes retrieved from the internet.

8. Insurance Information: State the name of your insurer and policy number. If you have been reimbursed by your insurance
company, you may not be eligible for compensation.

9. Are You the Registered Owner? Only the registered owner of the damaged vehicle or property may file a claim. Be sure to
provide all vehicle information.

10. Signature of Claimant: Please sign and date the claim form. The State of California does not accept claim forms without an
original signature. Faxed or photocopied claim forms will not be accepted.

If your claim is over $5,000.00, you must file a different form with the Victim Compensation and Government Claims Board
(VCGCB) WITHIN 6 MONTHS OF THE DATE OF INCIDENT. A form may be obtained by contacting the VCGCB at
P.O. Box 3035 Sacramento, CA 95812-3035 or calling 1-800-955-0045 or downloading the form from the web at
http://www.vcgcb.ca.gov/claims/default/aspx.

The fact that this brief statement of the initial procedure to be followed in submitting a claim against the State of California has been furnished to
you or that an investigation of any claim is undertaken is not to be taken as an admission of liability in any respect on the part of the state or any
of its officers or employees, nor is the fact that this informational statement has been furnished to you to be construed as a waiver of any
requirements imposed by the law or of any defense which may be available to the State of California in connection with any claim that may be
filed against it.