The LD-0274 form is a document used by individuals to file a claim of $10,000 or less against the California Department of Transportation (Caltrans) for death, personal injury, or for injury to personal property or growing crops, as outlined by specific sections of the Government Code. The form serves as a structured mechanism for California residents to seek compensation for damages or injuries caused by the Department of Transportation or its contractors, emphasizing the importance of providing personal information which enables the processing of such claims in compliance with federal and state laws. To embark on this crucial step towards asserting your rights after experiencing a qualifying incident, click the button below to fill out and submit the LD-0274 form.
When dealing with incidents involving the California Department of Transportation (Caltrans) that result in personal injury, damage to personal property, or to growing crops, individuals have the option to file a claim for amounts $10,000 or less using the LD-0274 form. This form serves as a critical step for those seeking compensation for damages incurred under specific circumstances. Created to streamline the process of filing claims against Caltrans, the LD-0274 form requires detailed information about the claimant, the incident causing damage, and the requested compensation. It binds claimants to provide thorough descriptions and evidence, such as the exact time and location of the incident, detailed accounts of how the damage or injury occurred, the assertion of Caltrans or its contractor's actions leading to the damage, and the precise amount being claimed, supported by estimates or receipts. Additionally, it underscores the importance of timely submission within six months from the date of the incident, as stipulated by the Government Code § 911.2, to avoid forfeiture of the claim. The form also emphasizes voluntary personal information submission, adhering to privacy laws, with the aim to expedite processing while ensuring claimants understand their rights to inspect personal records maintained by the agency. This introductory overview of the LD-0274 form outlines its purpose, requirements, and the procedural adherence expected from claimants, underpinning the form's role in facilitating claims against the California Department of Transportation for smaller amounts.
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
Filing a claim against the California Department of Transportation (Caltrans) for amounts of $10,000 or less is a structured process aimed at rectifying issues of personal injury or property damage due to actions attributable to Caltrans or its contractors. Adherence to the specified protocol and timelines is essential. Detailed steps guide claimants through the precise information and documentation required to foster a seamless claim processing experience. Keep in mind, an incomplete or incorrectly filled form can cause delays or result in the claim being returned unprocessed. Therefore, it is imperative to carefully follow the instructions and ensure all necessary information and supporting documents are accurately provided.
Completing the LD-0274 form accurately and in its entirety is critical for the timely processing of your claim. Ensure all supplemental documentation, such as estimates, receipts, and additional narratives, are attached as required. This careful attention to detail will support the efficient evaluation and resolution of your claim against Caltrans.
The LD-0274 form is utilized to file a claim against the California Department of Transportation (Caltrans) for amounts $10,000 or less. This includes claims for death, personal injury, injury to personal property, or damage to growing crops resulting from incidents involving Caltrans or its contractors.
This form should be completed either electronically or using a typewriter or print. All sections must be filled out with accurate and complete information. It's important to sign and date the form, as unsigned and undated forms will not be accepted for processing.
According to Government Code § 911.2, you have six months from the date of the incident to file your claim. Failure to submit the claim within this timeframe might result in the claim being denied due to missing the filing deadline.
When completing the LD-0274 form, the following information is required:
Failing to provide all the necessary information or submitting incomplete forms may result in delays in processing your claim or the return of your claim without any action taken. It's crucial to ensure that all sections are fully completed and supported with relevant documentation.
Yes, submitting additional documentation, such as photographs, police reports, or more detailed explanations attached to the LD-0274 form, is highly recommended. These documents can provide clearer evidence for your claim, facilitating a more efficient evaluation and processing by Caltrans.
After completing the LD-0274 form, sign and date it, then submit it to the appropriate district office address of the California Department of Transportation. Ensure that all additional supporting documentation is included with your submission. For claims exceeding $10,000, contact the Government Claims Program Office of Risk and Insurance Management within the Department of General Services for further instructions.
Not providing complete personal information: People often make the mistake of not filling in their full name, mailing address, e-mail address, and contact phone numbers. This information is crucial for allowing the department to reach out for any clarifications or further processing requirements.
Skipping details about the incident: It's common to see forms with vague or incomplete descriptions of the incident time, date, and location. For the department to assist effectively, specifying the exact month, day, year, time, county, highway number, direction of travel, and other location details is essential.
Leaving out how the injury or damage occurred: A detailed account of the events leading to the injury or damage is often missing. Providing complete details, including any supporting documents or additional pages if needed, helps in the evaluation of the claim.
Incomplete descriptions of Caltrans' or its contractor's actions: Many claimants fail to fully state what they believe Caltrans or its contractor did to cause the injury or damage. It's important to include all relevant facts and identify any individuals or entities involved.
Not specifying the injury or damage clearly: Sometimes, people do not clearly specify the type of injury or damage they are claiming. It is beneficial to include detailed descriptions, photographs, and supporting documents to provide a clear picture of the claim.
Omitting the dollar amount of the claim: A frequent oversight is not stating the total dollar amount being claimed. Submitting two written estimates or one paid receipt for damages and ensuring this section is completed are necessary steps to avoid having the claim deemed incomplete.
Common Mistakes to Avoid on the LD-0274 Form:
Not signing and dating the claim form, rendering it invalid.
Submitting the claim past the six-month deadline from the incident date, risking claim rejection.
Providing insufficient evidence to support the claim, such as lacking documentation or relevant photographs that clearly show the extent of the damage or injury.
Failing to check if additional pages or documents have been securely attached, possibly leading to incomplete claim submissions.
Overlooking the ADA Notice and failing to request accommodations or alternate formats for individuals with sensory disabilities, if needed.
When dealing with legal matters, especially something as specific as filing a claim against the Department of Transportation in California, it's crucial to be thorough and precise. The LD-0274 form is designed for claims of $10,000 or less, but it often works in tandem with other documents to ensure a comprehensive submission. Below is a list of forms and documents you may need alongside the LD-0274 form. This collection ensures that your claim is well-supported and clearly documented, improving the chance of a favorable resolution.
Each of these documents plays a vital role in building a compelling and complete claim package. Properly gathered, they not only bolster the narrative of events leading to damage or injury but also detail the financial impact on the claimant. Together with the LD-0274 form, these forms and documents facilitate a clear communication channel with the Department of Transportation, aiming to ensure every claim is thoroughly reviewed and justly resolved. Understanding what supports your claim can make the process smoother and more effective.
The LD-0274 form shares similarities with the Standard Form 95 (SF-95), which is used for claims against the United States for damage, injury, or death. Both forms serve as a notice to a governmental department about an individual’s intent to seek compensation due to injury or damage, requiring detailed personal information, incident specifics, and an accounting of damages.
Similar to the LD-0274 form, the Form 1-90 used for Green Card replacement involves providing detailed personal information and circumstances surrounding the need for the form's use. Both forms focus on individual case specifics, albeit for different governmental processes.
Workers' Compensation Claim forms, such as the DWC-1, resemble the LD-0274 in that both involve claims related to injuries. They require reporting detailed information about the incident, the nature of the injury or damage, and the claimant's personal details.
The LD-0274 and the Vehicle Damage Report forms found in many auto insurance claims processes have a lot in common. Each documents specific incidents leading to property damage, demands an account of the event, and asks for an estimation of losses.
The Property Loss Claim Form used by insurance companies mirrors the LD-0274 form in its requirement for claimants to detail the event that led to property loss, submit personal information, and provide a valuation of the claimed loss.
Similar to the LD-0274, the FEMA Disaster Assistance Form requires filers to provide a comprehensive account of loss or damage resulting from a disaster, including personal information, incident specifics, and loss details for government assistance eligibility.
Social Security Administration’s Form SSA-561-U2 (Request for Reconsideration) shares the aspect of disputing an initial decision with the LD-0274 form. Both require detailed personal information, specifics of the case, and a declaration of the perceived error or oversight by a governmental entity.
The Internal Revenue Service (IRS) Form 843 (Claim for Refund and Request for Abatement) is akin to LD-0274 in that it involves claiming a refund or challenging a mistake, requiring detailed information on the claimant’s part, specifics of the claim, and an explanation of why the refund or abatement is warranted.
Tenant Damage Report Forms, used by rental property management to document damages for which a tenant may be responsible, share commonalities with the LD-0274. Both require detailed descriptions of damage and its circumstances, though for different contexts and purposes.
Lastly, the structure and purpose of the LD-0274 form are comparable to Unemployment Insurance Benefit Forms. Applicants must provide personal information, details of their situation, and, in some cases, information on the cause of their unemployment, similar to how the LD-0274 asks for specifics on the incident and damages.
When filling out the LD-0274 form to claim against the Department of Transportation for amounts $10,000 or less, keeping certain dos and don'ts in mind will streamline the process and enhance the likelihood of your claim being properly processed. Here are some guidelines:
Remember, the information you provide is voluntary but crucial for processing your claim. Failure to provide requested information could significantly delay the process. Also, be aware of the six-month deadline from the date of the incident to file your claim, as per Government Code § 911.2, to ensure your claim is considered timely.
There are several misconceptions surrounding the LD-0274 form used to file a claim against the California Department of Transportation (Caltrans) for amounts $10,000 or less. Understanding these common errors can help claimants navigate the process more effectively.
Misconception 1: Personal information is optional. While the form states that providing personal information is voluntary, failing to provide essential details may delay processing. The information serves to facilitate the claim's processing, making it crucial for timely handling.
Misconception 2: You can file any time after an incident. A common error is believing that there is no deadline for filing. In reality, Government Code § 911.2 mandates a six-month period from the date of the incident to file a claim for personal injury or property damage.
Misconception 3: The form is only for vehicle-related claims. The LD-0274 form can be used for claims relating to personal injury, property damage, or damage to growing crops, not just vehicle-related issues.
Misconception 4: A lawyer must fill out the form. There's no requirement for legal representation to complete the form. Individuals can fill it out themselves, provided they provide all necessary information accurately.
Misconception 5: Any amount of damage can be claimed. The form is specifically designed for claims of $10,000 or less. Claims exceeding this amount must be filed with the Government Claims Program in West Sacramento, California.
Misconception 6: Submission guarantees compensation. Filing the form starts the claims process but does not guarantee compensation. Each claim is subject to review and must meet certain criteria for approval.
Misconception 7: Photographic evidence is not required. While not mandatory, attaching photographs and other supporting documents can significantly assist in the evaluation of your claim, providing clear evidence of the damage and its extent.
Misconception 8: Unsigned and undated forms are accepted. The form clearly states that unsigned and undated submissions will not be accepted. Ensuring the form is signed and dated is critical for it to be processed.
Misconception 9: The form covers claims against all California State Departments. The LD-0274 is specifically for claims against the California Department of Transportation. Claims against other state departments require different procedures.
Understanding and addressing these misconceptions can streamline the process of filing a claim, ensuring that all necessary information and documentation are correctly submitted, thereby avoiding unnecessary delays or rejections.
Filing a claim against the California Department of Transportation for amounts $10,000 or less requires meticulous attention to the details and procedures as outlined in the LD-0274 form. Here are four key takeaways that claimants should remember:
Overall, while the process may seem daunting, carefully following the instructions and providing thorough, accurate information can help in efficiently processing your claim against the Department of Transportation.
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