Claim Form

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Effective January 1, 2010, the Medicare Secondary Payer Act (Federal Law) requires the District to report all claims involving Bodily Injury and Medical Treatments to Medicare.

Please correct the field(s) marked in red below:

Claimant Information:

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Claimant Information:

Circumstance of the occurrence or transaction:

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Circumstance of the occurrence or transaction:
If you have documents and/or photographs to support your claim, upload them below.

Are there any witnesses to the incident?

Are there any witnesses to the incident?
Witness Information:
Name Address Telephone Number
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General description of the indebtedness, obligation, injury or loss incurred to date of claim submittal.
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Name of District employee(s) or Contractor(s) information causing the injury, damage or loss if known.

District Employee Name Contractor's Name Contractor's Staff Name
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  • If claim totals less than ten thousand dollars ($10,000) as of the date of presentation of the claim, including the estimated amount of any prospective injury, damage or loss, insofar as it may be known at the time of the presentation of the claim, together with the basis of computation of the amount claimed.
  • If claim is ten thousand dollars or more ($10,000), no dollar amount shall be included in the claim. However, it shall indicate whether the claim would be a limited civil case.
Claim Amount:

By typing your name below, you confirm that all information provided is true and accurate.

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By typing your name below, you confirm that all information provided is true and accurate.