Ld 0274 PDF Template

Ld 0274 PDF Template

The LD 0274 form is a claim form used to file against the California Department of Transportation for amounts of $10,000 or less. This form is specifically designed for individuals seeking compensation for personal injury, property damage, or other losses related to incidents involving Caltrans. To ensure a smooth process, it's essential to fill out the form completely and accurately.

If you're ready to submit your claim, please fill out the form by clicking the button below.

Article Guide

The LD 0274 form serves as a crucial tool for individuals seeking to file a claim against the California Department of Transportation 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. It includes sections for personal information, details about the incident, and the nature of the claim. Claimants must provide their full name, contact information, and a detailed account of the incident, including the time, date, and location. Additionally, the form requires a clear explanation of how the injury or damage occurred and what actions by Caltrans or its contractors are believed to have caused the issue. To support the claim, individuals must also specify the dollar amount being sought and provide relevant documentation, such as estimates or receipts. Completing the form accurately is essential, as any missing information may delay processing or result in the claim being returned. The form also includes important notices regarding personal information and deadlines for filing claims, emphasizing the need for timely submission. Understanding the requirements and following the instructions carefully can facilitate a smoother claims process.

Ld 0274 Preview

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)
PLEASE: Complete electronically or print or use a typewriter when filling out this form.
Sign and date claim form.
(UNSIGNED AND UNDATED FORMS WILL NOT BE ACCEPTED)
WARNING: GOVERNMENT CODE § 911.2
PROVIDES SIX MONTHS FROM THE DATE OF
INCIDENT TO FILE A CLAIM FOR PERSONAL
INJURY OR PROPERTY DAMAGE.
STATE USE ONLY
FILE NUMBER
1. NAME: LAST FIRST MIDDLE
HOME ADDRESS CONTACT PHONE NUMBER E-MAIL ADDRESS
CITY STATE ZIP CODE
2. IDENTIFY THE SPECIFIC TIME AND DATE FOR THE INCIDENT
CAUSING YOUR DAMAGE
TIME OF INCIDENT
AM
PM
DATE OF INCIDENT
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
YES NO
HOW MUCH DID INSURANCE PAY? $
YES NO
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.
HAVE YOU SUBMITTED A CLAIM TO YOUR INSURANCE CARRIER?
IF YES, WERE YOU PAID?
9. ARE YOU THE REGISTERED OWNER OF THE VEHICLE/DAMAGED PROPERTY?
I HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE FOREGOING
FACTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
REVERSE SIDE FOR STATE USE AND FILING INFORMATION ON CLAIMS.INSTRUCTIONS FOR FILLING OUT THIS FORM ARE ON
PAGE 3.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CLAIM AGAINST DEPARTMENT OF TRANSPORTATION FOR AMOUNTS $10,000 OR LESS
LD-0274 (REV 05/2017)
FOR STATE USE ONLY (BELOW)
DATE CLAIM RECEIVED REVIEWED BY: DISTRICT CLAIMS OFFICER
AMOUNT APPROVED $
DENIED
DENIAL DATE
STATE
RESPONSIBILITY
TORT FUND/
CONTRACT CONTINGENCY
CONTRACTOR
RESPONSIBILTY
LOCATION CODING
DISTRICT COUNTY ROUTE POSTMILE
COST CODING
DEPARTMENT FUND UNIT OBJECT PROJECT NUMBER PHASE
ITEM CHAPTER STATUTES FISCAL YEAR SCHEDULE NUMBER
ACCOUNTING OFFICER SIGNATURE
DATE
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.
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.
I hereby certify upon my own personal knowledge that the
budgeted funds are available for the period and purpose of the
expenditure stated above.
CLAIMS OFFICER
California Department of Transportation
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CLAIM AGAINST DEPARTMENT OF TRANSPORTATION FOR AMOUNTS $10,000 OR LESS
LD-0274 (REV 05/2017)
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:
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
The claim form may also be downloaded from the Government Claims Program website at:
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.
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.
↓ Ld 0274

File Properties

Fact Name Description
Form Purpose This form is used to file a claim against the California Department of Transportation for amounts of $10,000 or less related to personal injury, property damage, or growing crops.
Governing Laws The claims are governed by California Government Code sections 911.2 and 935.7.
Submission Deadline Claims must be submitted within six months from the date of the incident, as per Government Code § 911.2.
Personal Information Providing personal information is voluntary, but failure to do so may delay the processing of the claim.
Signature Requirement The form must be signed and dated. Unsigned or undated forms will not be accepted.

Instructions on Utilizing Ld 0274

After completing the LD 0274 form, it is important to ensure that all required information is accurately provided. This will help facilitate the processing of your claim against the California Department of Transportation. Once the form is filled out, it should be submitted according to the instructions provided, as failure to do so may delay the review of your claim.

  1. Claimant's Name and Contact Information: Enter your full name, mailing address, email address, and contact phone number.
  2. Date and Time of Incident: Specify the exact date and time of the incident that caused your injury or damage.
  3. Location of Incident: Describe the location in detail, including county, highway number, direction of travel, post mile, nearest exit, and cross streets. Consider attaching a map for clarity.
  4. Details of the Incident: Explain how your injury or damage occurred. Include as much detail as possible. If needed, attach additional pages.
  5. Claim Against Caltrans: State what actions or negligence by Caltrans or its contractor led to your injury or damage. Include names of involved parties if applicable.
  6. Injury or Damage Claimed: Specify the exact nature of your injury or damage. You may attach photographs or other supporting documents to illustrate your claim.
  7. Dollar Amount of Claim: Clearly state the total dollar amount you are claiming. Ensure this section is filled out to avoid your claim being returned.
  8. Insurance Information: Provide details about any insurance coverage, including the name of the insurer and policy number, if applicable.
  9. Signature and Date: Sign and date the form. Unsigned or undated forms will not be accepted.

Important Facts about Ld 0274

What is the purpose of the LD 0274 form?

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 applicable for claims related to personal injury, death, or damage to personal property and growing crops. It is essential to provide accurate information to facilitate the processing of your claim.

What information do I need to provide when filling out the form?

When completing the LD 0274 form, you must provide your full name, contact information, and details about the incident. This includes the date, time, and specific location of the incident. Additionally, you should describe how the injury or damage occurred, what actions you believe Caltrans or its contractor took to cause the injury, and the amount you are claiming. Supporting documents, such as estimates or receipts for damages, should also be included.

What happens if I do not complete all sections of the form?

Failure to complete all sections of the LD 0274 form may lead to delays in processing your claim or result in the return of your claim without action. It is crucial to provide comprehensive and accurate information to ensure a smooth review process.

Is there a time limit for submitting a claim using the LD 0274 form?

Yes, there is a time limit. According to Government Code § 911.2, you must file your claim within six months from the date of the incident that caused the injury or damage. It is important to adhere to this timeline to ensure that your claim is considered.

Common mistakes

When filling out the LD 0274 form, one common mistake is providing incomplete personal information. Claimants often overlook essential details such as their full name, mailing address, or contact phone number. This oversight can lead to delays in processing the claim. It is crucial to ensure that all requested personal information is filled out accurately to avoid complications.

Another frequent error involves the failure to specify the exact date and time of the incident. Claimants may provide vague information or leave this section blank. This is problematic because the California Department of Transportation requires precise details to evaluate the claim properly. To ensure smooth processing, it is advisable to double-check the accuracy of the date and time before submission.

Inaccurate or insufficient location descriptions can also hinder a claim. Many claimants do not provide enough detail about where the incident occurred. For instance, simply stating "on the highway" is not adequate. Instead, it is beneficial to include specifics such as the county, highway number, and nearest exit. Including a map can further assist in clarifying the incident's location.

When explaining how the injury or damage occurred, some claimants fail to provide comprehensive details. A vague description can lead to confusion and may result in the claim being denied. Providing a thorough account of the events that led to the injury or damage is essential. If more space is needed, attaching additional pages is encouraged.

Claimants sometimes neglect to specify what they believe Caltrans or its contractors did to cause their injury or damage. This section is critical for establishing liability. A clear and detailed explanation helps the reviewing officer understand the basis of the claim. Failing to include this information can lead to misunderstandings and potential denial of the claim.

Lastly, many individuals forget to include the dollar amount of their claim. Leaving this section blank can result in the claim being deemed incomplete. It is important to state the total amount clearly and to submit the required supporting documentation, such as estimates or paid receipts. Ensuring all financial details are included will help expedite the processing of the claim.

Documents used along the form

When filing a claim using the LD 0274 form, there are several additional documents that may be necessary to support your claim. Each of these documents serves a specific purpose in the claims process, helping to provide clarity and evidence regarding the incident in question. Below is a list of commonly used forms and documents that complement the LD 0274 form.

  • Police Report: This document provides an official account of the incident, detailing the circumstances and any involved parties. It can serve as crucial evidence in establishing the facts of the case.
  • Medical Records: If your claim involves personal injury, these records outline the nature and extent of your injuries. They can help substantiate your claims regarding medical treatment and related expenses.
  • Estimates or Receipts: Providing two estimates or one paid receipt for damages claimed is essential. These documents verify the financial impact of the incident and support the dollar amount you are claiming.
  • Witness Statements: Statements from individuals who witnessed the incident can provide additional perspectives and corroborate your account of what occurred. These can be valuable in strengthening your claim.

Gathering these documents will enhance the credibility of your claim and facilitate a smoother review process. Ensuring that all necessary information is included will help in achieving a favorable outcome.

Similar forms

  • LD-0275 Form: This form is also used to file claims against the California Department of Transportation, but it is specifically for amounts exceeding $10,000. It requires similar personal information and details about the incident.
  • LD-0276 Form: This document is utilized for claims related to property damage caused by state vehicles. It shares similarities in terms of required information about the claimant and the incident.
  • LD-0277 Form: This form addresses claims for personal injury resulting from state-operated public transportation. Like the LD-0274, it seeks personal details and specifics about the incident.
  • Government Claims Program Form: This form is needed for claims over $10,000 against the State of California. It requires similar information regarding the claimant and the nature of the claim.
  • California Highway Patrol Accident Report: This report documents traffic accidents and is often used in conjunction with claims. It includes details about the incident and the parties involved, similar to the LD-0274.
  • Insurance Claim Form: This document is used to file claims with insurance companies for damages. It typically requests similar information about the incident and the claimant.
  • Personal Injury Claim Form: This form is used for filing personal injury claims in civil court. It requires detailed information about the injury, similar to what is requested in the LD-0274.
  • Property Damage Claim Form: This form is designed for property damage claims in various contexts. It asks for specifics about the damage and the claimant, paralleling the information requested in the LD-0274.

Dos and Don'ts

When filling out the LD 0274 form, it is essential to follow specific guidelines to ensure proper processing of your claim. Below is a list of actions to take and avoid.

  • Do complete the form electronically, or print it clearly using a typewriter.
  • Do sign and date the form before submission. Unsigned and undated forms will be rejected.
  • Do provide detailed information about the incident, including exact time, date, and location.
  • Do attach any relevant documents, such as police reports or photographs of the damage.
  • Don't leave any sections of the form blank. Incomplete forms will delay processing.
  • Don't forget to include the total dollar amount of your claim; failure to do so will result in rejection.

Misconceptions

When it comes to the LD 0274 form, there are several misconceptions that can lead to confusion for those looking to file a claim against the California Department of Transportation. Here are nine common misunderstandings:

  • The form is only for large claims. Many believe the LD 0274 form is only applicable for claims exceeding $10,000. In fact, it is specifically designed for claims of $10,000 or less.
  • Personal information is mandatory. Some people think that all personal information requested on the form is mandatory. While providing this information is crucial for processing, it is technically voluntary. However, not providing it may delay your claim.
  • Claims can be filed anytime after an incident. There is a common belief that there is no deadline for filing claims. However, you must submit your claim within six months from the date of the incident, or it may be denied.
  • Unsigned forms will still be accepted. Many individuals think that submitting an unsigned form is acceptable. This is incorrect; unsigned and undated forms will not be accepted.
  • You do not need to provide evidence. Some claimants believe they can file a claim without any supporting documents. In reality, you should submit estimates or receipts to substantiate your claim.
  • Filing a claim guarantees compensation. There is a misconception that simply filing the form guarantees payment. This is not the case. Each claim is reviewed, and compensation is not assured.
  • Claims must be filed in person. Some individuals think they must file their claims in person. You can complete the form electronically and submit it by mail, which is often more convenient.
  • Providing a police report is optional. While some believe that a police report is not necessary, it is highly recommended to attach it if one exists. It can significantly strengthen your claim.
  • All claims are treated the same. Lastly, many people think that all claims are processed with the same level of urgency. However, the complexity and specifics of each claim can affect how quickly it is reviewed.

Understanding these misconceptions can help streamline the claims process and increase the likelihood of a successful outcome. Being informed is the first step toward ensuring your claim is handled appropriately.

Key takeaways

Here are some important points to consider when filling out and using the LD 0274 form:

  • Purpose of the Form: The LD 0274 form is used to file a claim against the California Department of Transportation for amounts of $10,000 or less.
  • Personal Information: Providing personal information is voluntary, but omitting details may delay the processing of your claim.
  • Submission Method: Complete the form electronically, print it, or use a typewriter. Handwritten forms are discouraged.
  • Signature Requirement: Ensure that you sign and date the form. Unsigned or undated forms will not be accepted.
  • Time Limit: You have six months from the date of the incident to file your claim for personal injury or property damage.
  • Detailed Incident Information: Clearly state the time, date, and specific location of the incident. Include as much detail as possible.
  • Explanation of Incident: Provide a thorough explanation of how the injury or damage occurred. Attach additional pages if necessary.
  • Claim Amount: Specify the dollar amount of your claim. Submit two estimates or one paid receipt to support your claim.
  • Insurance Information: If applicable, include details about your insurance coverage and any payments received.
  • Supporting Documents: Attach any relevant documents, such as photographs or police reports, to strengthen your claim.

Following these guidelines can help ensure that your claim is processed efficiently and effectively.