STATE OF CALIFORNIA - DEPARTMENT OF GENERAL SERVICES Government Claim Filing Instructions DGS ORIM 06 (Rev. 05/2017) Government Claims Program Office of Risk and Insurance Management Department of General Services P.O. Box 989052, MS 414 West Sacramento, CA 95798-9052 1-800-955-0045 www.dgs.ca.gov/orim/Programs/GovernmentClaims.aspx Filing Fee Requirement The Government Code requires a $25.00 filing fee for all claims presented to the Office of Risk and Insurance Management (ORIM). Materials submitted without a filing fee will not be processed. Checks or Money Orders should be made out to the State of California. If you cannot afford the filing fee, you may request a waiver. For most claim types, the filing fee is refunded if the claim is paid. IMPORTANT NOTICE REGARDING CLAIMS FOR STALE-DATED WARRANTS (UNCASHED CHECKS): Due to changes in State law, effective July 1, 2016, claims for stale-dated warrants (uncashed checks) DO NOT require the $25.00 filing fee and should be filed directly with the department that issued the original check. For example, claims for stale-dated State tax refund checks should be filed with the Franchise Tax Board. However, this form can be used to file such claims. For more information, please contact GCP at 1-800-955-0045. What types of claims can be filed with Government Claims? Claims can be filed for losses you believe were caused by the action, or inaction, of a state agency. Claims may include: · Damage to real or personal property · Refund of a tax, fee, or penalty · Reimbursement for state employee property · Contract disputes loss, benefits, salary, or travel expenses What types of claims should not be filed with Government Claims? Claims against local government agencies must be filed with the responsible local agency. Claims against a University of California (UC) campus must be filed with the UC Regents. Claims against a California State University (CSU) campus must be filed with the campus itself. Claims against school districts or community college districts must be filed with the responsible district. Claims against judicial branch entities must be filed with the Judicial Council. Delegated Authority Claims The VCGCB grants some agencies delegated authority to resolve claims under $1,000.00. If you have a claim for less than $1,000.00, you may file directly with the following entities: California State Teachers' Retirement System, Department of State Hospitals, Department of Motor Vehicles, California Highway Patrol, Department of Consumer Affairs, California Department of Corrections and Rehabilitation, California State Coastal Conservancy, and Department of GeneralServices. The Delegated Authority of the California Department of Transportation (Caltrans) By law, Caltranshas delegated authority to resolve claims for dollar amounts within the jurisdiction of the small claims courts. The current jurisdiction of the small claims courts is $10,000.00. Therefore, you may file claims for damages less than $10,000.00 directly with Caltrans. Claims for Subrogation: Claims for subrogation should name the insurance company seeking compensation as the claimant. The insurance company employee handling the claim should be named the representative. Please provide the name of your insured in the space provided (section 7). What are the time limits for filing a claim? Claims relating to the death or injury of a person, or damage to personal property or crops, must be filed no later than six months after the date of the incident. Other claims must be filed no later than one year after the date of the incident. You can request permission to file a late claim. You may want to consult an attorney if you are not sure how the time limits apply to your claim. Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for filling out this form: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Provide the full name of the person claiming damage or injury. If the claimant is a business or entityother than an individual, put the name of the entity here. Provide a daytime telephone number. Provide an email address. (Optional) Provide a complete mailing address. If you are an inmate or a patient at a state hospital, please provide your identificationnumber. If the claim is being filed on behalf of a minor (someone younger than 18), please give the minor's birthdate. If you are an insurance company claiming subrogation, please provide your insured's name here. If your claim relates to another claim or claimant, please provide the claim number or claimant's namehere. You may wish to consult an attorney for assistance with filing a claim, however it is not required. If an attorney or other person (such as the parent or legal guardian of a minor or conservator of an adult) is representing you, please complete this section. If this section is completed, all correspondence regarding this claim will be sent to the representative. Provide a daytime telephone number, including area code, for the attorney or representative. Provide an email address for the attorney or representative. (Optional) Provide a complete mailing address for the attorney or representative. Describe the relationship of the attorney or representative to the claimant. If this claim is regarding a stale-dated warrant (an uncashed check) more than three years old, providethe: · date of issue · warrant number · amount · The name of the agency that issued it. Attach a copy of the front and back of the warrant. Please note: It is best to claim replacement warrants directly from the agency that issued the originals. State the exact date of the incident that you believe caused the damage or injury. · If the incident took place over more than one date, provide both the beginning and ending dates. · If the incident is ongoing, please provide the beginning date and the most recent date it occurred. · Late Claims: o The Board must receive claims relating to the death or injury of a person, or damage to personal property or growing crops, no later than six months after the date of the incident. o If your claim is for equitable indemnity, the filing deadline is six months after the date you were served with the underlying lawsuit. If such a claim is filed more thansix months from the date of the incident, attach a written explanation for filing late. Other claims with deadlines must be received no later than one year after the incident date. · Provide the name of the state agency that you believe caused the damage or