The LD-0274 form serves as a formal claim against the California Department of Transportation for damages amounting to $10,000 or less, involving personal injury, property damage, or harm to growing crops under specific sections of the Government Code. Detailed personal information is requested with the form in accordance with the Federal Privacy Act and the Information Practices Act of 1977 to aid in processing, though failure to provide complete information may delay or affect the processing of the claim. For those looking to initiate a claim for injuries or damages incurred, click the button below to start filling out the LD-0274 form.
When it comes to navigating the aftermath of incidents involving the California Department of Transportation (CalDOT), the LD-0274 form serves as a crucial gateway for those seeking compensation for damages of $10,000 or less. This particular document, revised in May 2017, is designed to streamline the claim process for individuals who have experienced either personal injury or property damage due to the actions or negligence of the Department or its contractors. From the outset, the form emphasizes the importance of providing personal information voluntarily, under the guidance of federal and state privacy laws, to facilitate the smooth processing of claims. It outlines the necessity of completing the form with accuracy, either electronically, by typing, or in print, and underscores the critical role of the claimant's signature and the submission date. The LD-0274 form is not just a paper trail; it is a structured pathway designed to ensure that claims are lodged within the strict six-month window post-incident, as mandated by Government Code § 911.2. With sections meticulously laid out to capture every detail of the incident—from the specifics of the time and location to a narrative of how the incident occurred, the perceived cause of injury or damage, through to the financial quantification of the claim—the form acts as both a record and a review tool. Significantly, it also offers guidance for claims exceeding $10,000, directing claimants to the Government Claims Program for further action. Furthermore, the form includes provisions for those with sensory disabilities, ensuring accessibility in line with the ADA, by offering alternate formats upon request. Ultimately, the LD-0274 form embodies the State of California's commitment to accountability, while also navigating the fine balance between bureaucratic requirement and the individual's right to compensation.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CLAIM AGAINST DEPARTMENT OF TRANSPORTATION FOR AMOUNTS $10,000 OR LESS
LD-0274 (REV 05/2017)
PERSONAL INFORMATION NOTICE
Pursuant to the Federal Privacy Act (Section 552 et seq.) and the Information Practices Act of 1977 (IPA) (Civil Code Sections 1798 et seq.), notice is hereby given for the request of personal information by this form. The requested personal 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.
Use this form to file a claim of $10,000 or less against the California Department of Transportation for death or personal injury, or for injury to
personal property or growing crops. (Government Code sections 911.2, 935.7)
WARNING: GOVERNMENT CODE § 911.2
PLEASE:
Complete electronically or print or use a typewriter when filling out this form.
PROVIDES SIX MONTHS FROM THE DATE OF
INCIDENT TO FILE A CLAIM FOR PERSONAL
Sign and date claim form.
INJURY OR PROPERTY DAMAGE.
(UNSIGNED AND UNDATED FORMS WILL NOT BE ACCEPTED)
STATE USE ONLY
1. NAME:
LAST
FIRST
MIDDLE
FILE NUMBER
HOME ADDRESS
CONTACT PHONE NUMBER
E-MAIL ADDRESS
CITY
STATE
ZIP CODE
2. IDENTIFY THE SPECIFIC TIME AND DATE FOR THE INCIDENT
TIME OF INCIDENT
AM
DATE OF INCIDENT
CAUSING YOUR DAMAGE
PM
3.STATE THE LOCATION OF THE INCIDENT (COUNTY, HIGHWAY, NEAREST OFF-RAMP, CROSS STREET, OR POSTMILE).
COUNTY
ROUTE
DIRECTION
POSTMILE
CROSS STREET
DESCRIBE THE INCIDENT LOCATION (FOR EXAMPLE: "JUST NORTH OF 1ST STREET, IN THE NUMBER 1 LANE")
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? (SUBMIT TWO ESTIMATES OR ONE PAID RECEIPT)
$
8. INSURANCE INFORMATION
NAME OF INSURER
POLICY NUMBER
YES
NO
HOW MUCH DID INSURANCE PAY?
MAKE OF VEHICLE
MODEL
COLOR
YEAR
VEHICLE LICENSE NO.
10. SIGNATURE OF CLAIMANT
DATE
ADA Notice
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
Management Unit at (279) 234-2284, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
FOR STATE USE ONLY (BELOW)
DATE CLAIM RECEIVED
REVIEWED BY: DISTRICT CLAIMS OFFICER
AMOUNT APPROVED $
TORT FUND/
CONTRACTOR
DENIED
RESPONSIBILITY
CONTRACT CONTINGENCY
RESPONSIBILTY
DENIAL DATE
DISTRICT
LOCATION CODING
COUNTYROUTE
COST CODING
DEPARTMENT
FUND
UNIT
OBJECT
PROJECT NUMBER
PHASE
ITEM
CHAPTER
STATUTES
FISCAL YEAR
SCHEDULE NUMBER
ACCOUNTING OFFICER SIGNATURE
FOR CLAIMS TEN THOUSAND DOLLARS ($10,000) OR LESS
Select District
Address
FOR CLAIMS OVER TEN THOUSAND DOLLARS ($10,000)
You must file a claim with the Government Claims Program in West Sacramento, California.
If you have any questions about claims of more than ten thousand dollars ($10,000), contact:
Government Claims Program
Office of Risk and Insurance Management
Department of General Services
P.O. Box 989052, MS 414
West Sacramento, CA 95798-9052
Phone: 1-800-955-0045
E-mail: gcinfo@dgs.ca.gov
Website: http://www.dgs.ca.gov/orim/Programs/GovernmentClaims.aspx
The fact that this brief statement of the initial procedure to be followed in submitting a claim against the State of California, or against any of the State of California's subdivisions, departments, divisions, agencies, officers, employees, agents, or directors, 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 of California, or by any of the State of California's subdivisions, departments, divisions, agencies, officers, employees, agents, or directors, 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 or to any of the State of California's subdivisions, departments, divisions, agencies, officers, employees, agents, or directors, in connection with any claim that may be filed.
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, e-mail address, and contact telephone number(s) of the person or entity claiming property damage, personal injury, or other loss.
2.Date and Time When the Injury/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 county, highway number, direction of travel, post mile, nearest exit(s), cross-streets, and any additional information indicating where the incident giving rise to the claim occurred. Providing a map is optional, but advised. The more information you provide, the easier it is for us to assist you. You should also attach a copy of the police report (if one exists) of the incident.
4.How Your Injury/Damage Occurred: Provide complete details about what happened to cause your injury/damages. If you need more space, you may attach additional pages.
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. Identify 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 contractor, and the State of California vehicle license plate/ID number. If you need more space, you may attach additional pages.
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. If you need more space, you may attach additional pages. You can attach photographs and any additional supporting documents. If you do, be sure the photographs show the damage and its size relative to the vehicle. More than one photograph provides more information to assist the evaluation of your claim.
7.What Is the Dollar Amount of Your Claim? State the total dollar amount for which you are claiming. Leaving the dollar amount blank will result in your claim being deemed incomplete, and your claim will be returned without further action. Please submit two (2) written estimates and/or one (1) paid receipt for all damages claimed. If 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 of the Vehicle/Damaged Property? Only the registered owner may file a claim for damage to a vehicle or property. Be sure to provide all vehicle information, including a copy of the vehicle's registration.
10.Signature of Claimant: Please sign and date the claim form. Caltrans does not accept claim forms without an original signature. Faxed or photocopied claim forms will not be accepted.
Mailing Completed Form: The completed form must be mailed to the District Claims Office assigned to the county in which your injury/ damages occurred. To determine the proper District Claims Office to which you should mail your completed form, you can use the map on the website and click on the county. The website map will show the District Claims Office responsible for that county, including its address and telephone number. You can then use the drop down menu on page 2 of this form to automatically fill in the address for the appropriate District Claims Office. If you have any questions about the location where your injury/damages occurred, you can contact any District Claims Office.
If your claim is over ten thousand dollars ($10,000.00), you must file a different form with the Government Claims Program WITHIN 6 MONTHS OF THE DATE OF INCIDENT. A claim form may be obtained by contacting the Government Claims Program at:
Office of Risk and Insurance Management Department of General Services
West Sacramento, CA 95798-9052 Phone: 1-800-955-0045
The claim form may also be downloaded from the Government Claims Program website at:
http://www.dgs.ca.gov/orim/Programs/GovernmentClaims.aspx
When it comes to dealing with an unpleasant event that involves a claim against the Department of Transportation in California for an amount of $10,000 or less, knowing the step-by-step process to fill out the LD-0274 form is key. This form is your gateway to officially lodging your complaint whether it pertains to personal injury, property damage, or both. It's a direct approach to seek compensation for damages that you believe have been caused by the actions or negligence of the state's transportation department or its contractors. Keep in mind that the clock is ticking; you have six months from the date of the incident to file your claim. The procedure is straightforward, but attention to detail is crucial. Here's how to do it right:
After completing these steps, your claim will be on its way through the official channels. Remember, while filling out the form is a crucial part of the claims process, it represents just the beginning of a series of actions that may involve further documentation, inspection, and potentially, negotiations. Equip yourself with patience and persistence, and keep copies of all correspondence and documents related to your claim for your records. It’s also a good idea to familiarize yourself with the corresponding laws and regulations that govern the claims process, ensuring you’re adequately prepared for any questions or requests for additional information.
What is the LD-0274 form used for?
The LD-0274 form is designed for filing claims against the California Department of Transportation (Caltrans) for amounts of $10,000 or less. These claims can be related to death or personal injury, or injury to personal property or growing crops resulting from incidents for which Caltrans or its contractors may be considered liable.
Who needs to fill out the LD-0274 form?
Individuals or entities seeking compensation for damages or injury of $10,000 or less, which they believe were caused by the actions or negligence of the California Department of Transportation or its contractors, must complete this form.
What personal information do I need to provide on the LD-0274 form?
You must provide your full name, mailing address, email address, and contact telephone number(s). This information is necessary to process your claim.
Is there a deadline for filing the LD-0274 form?
Yes, according to Government Code § 911.2, you have six months from the date of the incident to file a claim for personal injury or property damage. Failure to file within this timeframe may result in your claim being denied.
What specific information about the incident is required on the LD-0274 form?
You need to identify the specific time and date of the incident, as well as the location, including the county, highway, nearest off-ramp, cross street, or post mile. A detailed description of how the injury or damage occurred, along with any actions by Caltrans or its contractors that you believe caused your injury or damage, must be included.
How detailed should the ex
Filling out the LD-0274 form, which is used to claim against the California Department of Transportation for amounts of $10,000 or less, requires attention to detail and accuracy. Here are seven common mistakes people make when completing this form:
Not providing complete personal information: Claimants often forget to fill out every section that requests personal information such as their full name, mailing address, email address, and contact telephone numbers. This oversight can result in delays.
Incorrect or vague information about the time and date of the incident: It is crucial to state the exact month, day, year, and time when the incident occurred. Ambiguity or inaccuracies can affect the processing of the claim.
Omitting detailed location of the incident: Failing to specify the county, highway number, direction of travel, and post mile or nearest exits can lead to difficulties in verifying and investigating the claim.
Not explaining how the injury or damage occurred in detail: A lack of detailed explanation about the circumstances leading to the injury or damage can result in insufficient evidence to support the claim.
Leaving out information on how Caltrans or its contractor is responsible: Many claimants forget to include details on why they believe Caltrans or its contractor caused their injury or damage, including any identifying information of the personnel or vehicles involved.
Not specifying the claimed injury or damage accurately: Claimants sometimes fail to clearly describe the specific injuries or damages they are claiming, including the failure to attach photographs or relevant supporting documents.
Not stating the dollar amount of the claim or providing insufficient documentation: Some individuals either leave the dollar amount section blank or do not provide the required two written estimates or one paid receipt, which is essential for the claim's assessment.
Avoiding these mistakes can help ensure the claim process is as smooth and swift as possible. Remember, providing complete and accurate information is key to facilitating the processing of any claim.
When submitting a claim against the Department of Transportation in California for amounts of $10,000 or less using the LD-0274 form, it's important to be thoroughly prepared. This means having all necessary documentation ready to support your claim. Alongside the LD-0274, there are several other forms and documents that you might need to ensure your claim is processed smoothly. Understanding these documents will help you navigate the process more effectively.
Navigating the claims process requires careful attention to detail and thorough documentation. By gathering these documents alongside your LD-0274 form, you’ll be better equipped to present a comprehensive claim to the California Department of Transportation. Remember, the more evidence you provide, the clearer your claim becomes, easing the investigation and resolution process. If you have any uncertainties about what is needed, consulting with a legal advisor can shed light on how to proceed confidently.
Small Claims Court Paperwork: Similar to the LD 0274 form, small claims court documents are designed for individuals to seek compensation or dispute matters, typically involving amounts up to a certain threshold, such as $10,000. These forms require detailed information about the claim, including personal information, the nature of the claim, evidence supporting the claim, and the amount being sought. Both focus on accessibility for non-lawyers.
Insurance Claim Forms: These documents are also akin to the LD 0274 form as they are used to claim compensation, in this case from an insurance company, for damages or loss. They require the claimant to furnish personal information, details of the incident (time, date, location), a description of the damage or loss incurred, and the amount claimed, mirroring the structure of LD 0274.
Property Damage Report Forms: Similar to the LD 0274, these forms are used to report and claim damages to property. They require comprehensive details about the incident, including when and where it occurred, a description of the damage, the cause, and an estimate of repair costs. Both forms serve the purpose of formally documenting incidents leading to damage for compensation.
Personal Injury Claim Forms: Used by individuals to claim compensation for injuries suffered, these forms share commonalities with LD 0274 by requiring extensive details about the injury incident, including the date, time, location, a description of how the injury occurred, and the nature of the injury. They also necessitate disclosure of personal information and often include an estimation of the medical costs or losses incurred.
Worker’s Compensation Claim Forms: These forms are specifically designed for employees to report work-related injuries or illnesses, seeking compensation. Like the LD 0274 form, they require detailed incident reporting, including personal information, specific details of how, when, and where the injury or illness occurred, a description of the injury or illness, and the claim amount or type of compensation being sought.
When filling out the LD-0274 form to submit a claim against the California Department of Transportation for amounts $10,000 or less, following these guidelines will help ensure your claim is processed smoothly:
Following these guidelines carefully will help streamline the process and improve the chances of a successful claim submission.
When discussing the LD 0274 form, several misconceptions can arise, mainly due to its specific legal and procedural context. Understanding these misconceptions is vital to ensure that individuals accurately complete and submit their claims against the California Department of Transportation (Caltrans) for amounts of $10,000 or less. Below are five common misconceptions about the LD 0274 form:
Clearing up these misconceptions is crucial for individuals looking to file a claim against Caltrans. Accurate comprehension of the LD 0274 form's requirements and the process can significantly impact the effectiveness and outcome of one's claim.
When dealing with the LD-0274 form for claims against the California Department of Transportation, it's essential to grasp the key factors that will ensure your claim is processed efficiently and effectively. Here are four vital takeaways to guide you through filling out and using the form:
In summary, properly filling out the LD-0274 form requires attention to detail, timeliness, comprehensive information, and adequate documentation. Understanding and adhering to these points are essential steps toward successfully filing a claim of $10,000 or less against the California Department of Transportation for injury or damage.
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