The LD 0274 form is a document utilized by individuals wishing to file a claim against the California Department of Transportation for amounts of $10,000 or less. This form is specifically designed to address claims related to personal injury, property damage, or other losses that may have occurred due to incidents involving the Department. Completing this form accurately is crucial, as it facilitates the processing of claims and ensures timely consideration.
To initiate your claim, please fill out the form by clicking the button below.
Filing a claim against the California Department of Transportation can be a daunting task, especially when dealing with personal injuries or property damage. The LD 0274 form serves as a crucial tool for individuals seeking compensation for amounts of $10,000 or less. This form is specifically designed for claims related to incidents involving the Department of Transportation, whether it be for personal injury, death, or damage to property or crops. It is essential to complete the form accurately, as any missing information could delay the processing of your claim. The form requires personal details, including your name, contact information, and specifics about the incident, such as the time, date, and location. Additionally, you will need to explain how the injury or damage occurred and the nature of your claim against Caltrans or its contractors. Remember, it is vital to submit the required documentation, such as estimates or receipts, to support your claim. Timeliness is also key, as California law mandates that claims must be filed within six months of the incident. Understanding the nuances of this form can significantly impact the outcome of your claim, so taking the time to familiarize yourself with its requirements is essential.
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 is a straightforward process, but it requires careful attention to detail. By accurately completing the LD 0274 form, you can ensure that your claim is processed efficiently. Here's how to fill it out step by step.
After you have completed the form, make sure to review it for accuracy before submitting it. This will help avoid delays in processing your claim. Once submitted, your claim will be reviewed by the appropriate department, and you will receive further communication regarding its status.
The LD 0274 form is used to file a claim against the California Department of Transportation (Caltrans) for amounts of $10,000 or less. This form is specifically designed for claims related to personal injury, property damage, or damage to growing crops. By submitting this form, individuals can seek compensation for their losses as a result of incidents involving Caltrans or its contractors.
To properly complete the LD 0274 form, you will need to provide several key pieces of information:
Completing all sections accurately is crucial, as missing information may delay the processing of your claim.
It is important to note that you have six months from the date of the incident to file your claim. This deadline is mandated by Government Code § 911.2. If you miss this deadline, your claim may be denied, and you will lose the opportunity to seek compensation.
Failure to provide all requested information can lead to delays in processing your claim. In some cases, your claim may be returned without further action. To avoid this, ensure that you complete every section of the form and provide any necessary supporting documents. This will help facilitate a smoother review process.
Yes, you are encouraged to submit additional documents that support your claim. This may include photographs of the damage, police reports, or any other relevant evidence. Providing comprehensive documentation can strengthen your case and assist in the evaluation of your claim.
Filing a claim using the LD 0274 form can be a straightforward process, but many individuals make common mistakes that can delay or even derail their claims. Understanding these pitfalls is crucial for a successful submission.
One significant mistake is failing to provide complete personal information. It is essential to include your full name, mailing address, email address, and contact phone number. Omitting any of these details can lead to processing delays. Ensure that all information is accurate and up-to-date.
Another frequent error occurs when individuals do not specify the exact time and date of the incident. The form requires precise details, including the month, day, year, and time. Inaccuracies in this section can create confusion and complicate the review process.
Many claimants neglect to describe the location of the incident adequately. Providing vague information such as "on the highway" is insufficient. Instead, specify the county, highway number, direction of travel, and any landmarks. The more specific you are, the easier it will be for the Department of Transportation to assess your claim.
Additionally, some individuals fail to explain how the injury or damage occurred in detail. This section is critical for establishing the basis of your claim. A lack of clarity can lead to misunderstandings about the nature of your claim and its legitimacy.
Claimants often overlook the importance of stating what exactly Caltrans or its contractor did to cause the injury or damage. This section should include all relevant facts and identify any parties involved. A detailed account can significantly strengthen your case.
When it comes to the injury or damage claimed, individuals sometimes provide vague descriptions. It is vital to be specific about the injuries or damages sustained. Attach any supporting documents or photographs that can help illustrate your claim.
Another common mistake is leaving the dollar amount of the claim blank. This omission can result in the claim being deemed incomplete. Always ensure that you state the total dollar amount and submit the required estimates or receipts to support your claim.
Insurance information is another area where mistakes are frequently made. Some claimants either fail to include this information or do not provide accurate details about their insurance policy. This information is crucial for processing your claim efficiently.
Lastly, individuals often forget to sign and date the claim form. An unsigned or undated form will not be accepted, which can lead to unnecessary delays. Always double-check that you have completed this essential step before submitting your claim.
By avoiding these common mistakes, you can streamline the process of filing your claim against the California Department of Transportation. Taking the time to ensure that your form is complete and accurate can significantly enhance your chances of a successful outcome.
When filing a claim using the LD 0274 form, there are several other documents and forms that may be necessary to support your claim. Each of these documents serves a specific purpose and can help streamline the process. Understanding these forms can alleviate some of the stress associated with filing a claim.
Gathering these documents can be a time-consuming task, but they are essential for a thorough and successful claim process. By preparing these forms in advance, claimants can help ensure that their claim is processed efficiently and fairly.
When filling out the LD 0274 form for a claim against the California Department of Transportation, it’s essential to follow certain guidelines to ensure your submission is complete and processed efficiently. Here’s a list of things you should and shouldn’t do:
By following these guidelines, you can help ensure that your claim is processed smoothly and without unnecessary delays.
Understanding the LD 0274 form can be challenging. Here are seven common misconceptions about this form and clarifications to help you navigate the claims process more effectively.
This form can be used for various claims, including personal injury, property damage, and even injury to crops. It's not limited to vehicle-related incidents.
There is a strict six-month deadline from the date of the incident to file your claim. Missing this deadline can result in your claim being denied.
While providing personal information is voluntary, failing to do so may delay the processing of your claim. It’s in your best interest to complete all sections.
Submitting supporting documents, such as photographs and estimates, strengthens your claim. It is advisable to attach these materials to help clarify your situation.
Unsigned and undated forms will not be accepted. Ensure you sign and date your claim to avoid delays.
The form must be completed electronically, printed, or typed. Handwritten submissions may lead to errors and complications in processing.
Submitting this claim does not imply that the State of California or its agencies admit any liability. It is merely a request for compensation based on your claims.
When filling out and using the LD 0274 form, keep these key takeaways in mind: