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The LD 0274 form serves as a critical 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, death, or damage to personal property and crops. It is essential for claimants to provide accurate personal information, including their name, contact details, and a clear description of the incident. The form requires details such as the date, time, and location of the incident, along with an explanation of how the injury or damage occurred. Claimants must also specify what actions they believe Caltrans or its contractors took that led to their injury or damage. To support their claims, individuals are required to submit a dollar amount along with estimates or receipts for any damages incurred. Importantly, claimants must complete the form accurately and sign it, as unsigned or undated submissions will not be accepted. Additionally, there is a strict six-month deadline from the date of the incident to file such claims, making timely submission crucial for those affected. The LD 0274 form not only facilitates the claims process but also ensures that individuals are informed of their rights regarding personal information, in accordance with privacy laws.

Sample - Ld 0274 Form

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

 

 

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.

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 $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

TORT FUND/

CONTRACTOR

DENIED

RESPONSIBILITY

CONTRACT CONTINGENCY

RESPONSIBILTY

DENIAL DATE

 

 

 

 

 

 

 

 

DISTRICT

LOCATION CODING

COUNTYROUTE

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: [email protected]

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.

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: [email protected]

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 PDF

File Specs

Fact Name Fact Description
Form Purpose This form is used to file a claim for amounts of $10,000 or less against the California Department of Transportation.
Governing Laws The form is governed by Government Code sections 911.2 and 935.7.
Submission Requirements Claims must be signed and dated; unsigned and undated forms will not be accepted.
Time Limit Claims for personal injury or property damage must be filed within six months from the date of the incident.
Privacy Notice Personal information requested on the form is voluntary and protected under the Federal Privacy Act and the Information Practices Act of 1977.

Ld 0274 - Usage Guidelines

Filling out the LD 0274 form is an essential step in submitting a claim against the California Department of Transportation for amounts of $10,000 or less. After completing the form, ensure that you sign and date it before submission. Remember, unsigned or undated forms will not be accepted.

  1. Claimant's Information: Enter your full name, including last, first, and middle names. Provide your home address, contact phone number, and email address.
  2. Incident Details: Specify the exact time and date of the incident that caused your damage. Include AM or PM designation.
  3. Location of Incident: Describe the incident location, mentioning the county, highway, nearest off-ramp, cross street, or postmile. Provide additional details, such as "just north of 1st Street, in the number 1 lane."
  4. Incident Description: Explain how the injury or damage occurred. Be as detailed as possible.
  5. Claim Against Caltrans: Describe what you believe Caltrans or its contractor did to cause your injury or damage.
  6. Details of Injury or Damage: Specify the injury or damage you are claiming. Include all relevant details.
  7. Claim Amount: State the total dollar amount of your claim. Remember to submit two estimates or one paid receipt.
  8. Insurance Information: Provide the name of your insurer, policy number, and how much insurance paid, if applicable.
  9. Vehicle Information: If relevant, include details about the vehicle involved, such as make, model, color, year, and license number.
  10. Signature: Sign and date the form to validate your claim.

Your Questions, Answered

What is the LD 0274 form?

The LD 0274 form is a claim form used to file a claim against the California Department of Transportation for amounts of $10,000 or less. This form is specifically for claims related to personal injury, death, or damage to personal property or crops. It is important to complete this form accurately to ensure proper processing of your claim.

Who can file a claim using the LD 0274 form?

Any individual or entity that has experienced personal injury, property damage, or other losses due to the actions of the California Department of Transportation or its contractors can file a claim using the LD 0274 form. Make sure to provide complete and accurate information to support your claim.

What information do I need to provide on the form?

You will need to provide personal information, including your name, address, and contact details. Additionally, you must specify the date and time of the incident, the location, how the injury or damage occurred, and what you believe caused it. Don't forget to include the dollar amount of your claim and any supporting documents, such as estimates or receipts.

What is the deadline for filing a claim?

According to Government Code § 911.2, you have six months from the date of the incident to file your claim. Missing this deadline may result in your claim being denied, so it’s crucial to submit the form promptly.

What happens if I don’t complete all sections of the form?

If you fail to complete all sections of the LD 0274 form, it may delay the processing of your claim or result in the return of your claim. Ensure that every required section is filled out accurately to avoid any issues.

What should I do if my claim is denied?

If your claim is denied, you may want to seek further information on why it was rejected. You can also consider consulting with a legal professional for advice on your options, including whether to appeal the decision or pursue other legal avenues.

Is there assistance available for completing the form?

Yes, if you need help, you can contact the Forms Management Unit for guidance. They can provide information on how to fill out the form correctly. Additionally, if you have sensory disabilities, alternate formats of this document are available upon request.

Common mistakes

  1. Not providing complete personal information. Ensure that your full name, address, email, and phone number are clearly stated.

  2. Failing to sign and date the form. Unsigned or undated forms will be rejected.

  3. Omitting the specific date and time of the incident. This information is crucial for processing your claim.

  4. Inadequately describing the location of the incident. Provide detailed information, including county, highway number, and nearby landmarks.

  5. Not explaining how the injury or damage occurred. Provide a thorough account of the events leading to your claim.

  6. Neglecting to specify what Caltrans or its contractor did to cause your injury or damage. Clearly outline their actions or inactions.

  7. Leaving the amount of your claim blank. Always include a dollar amount; otherwise, your claim will be deemed incomplete.

  8. Failing to provide insurance information. Include the name of your insurer and policy number, if applicable.

  9. Not attaching supporting documents. Include estimates, receipts, or photographs to substantiate your claim.

  10. Ignoring the six-month deadline for filing claims. Ensure your claim is submitted within this timeframe to avoid rejection.

Documents used along the form

When filing a claim using the LD 0274 form against the California Department of Transportation, several other documents may be required to support your claim. Each document serves a specific purpose and helps to clarify the details of the incident. Below is a list of commonly used forms and documents that can accompany the LD 0274 form.

  • Police Report: This document provides an official account of the incident. It includes details such as the date, time, location, and parties involved. Submitting a police report can strengthen your claim by providing corroborative evidence.
  • Estimates for Damages: Two written estimates from repair shops or contractors are often necessary. These estimates should outline the costs associated with repairing any property damage claimed in your form.
  • Paid Receipts: If repairs have already been made, a paid receipt is essential. This document proves that you have incurred expenses related to the claim.
  • Photographs: Visual evidence of the damage can be very helpful. Photographs showing the extent of the damage, as well as the location of the incident, can provide additional context.
  • Insurance Information: If you have insurance coverage related to the incident, include details about your insurer and the policy number. This information helps clarify any potential overlap in claims.
  • Witness Statements: If there were witnesses to the incident, their statements can be valuable. These accounts can support your version of events and provide additional evidence.
  • Medical Records: If your claim involves personal injury, medical records documenting your injuries and treatment can substantiate your claim. These records should detail the nature and extent of the injuries sustained.
  • Claimant's Identification: A copy of the claimant’s identification may be required to verify the identity of the person submitting the claim. This helps ensure that the claim is legitimate.

Gathering these documents when filing your claim can help facilitate the process and increase the chances of a favorable outcome. Ensure that all necessary information is accurate and complete to avoid delays in processing your claim.

Similar forms

The LD 0274 form is similar to the Notice of Claim form, which is often used to notify a government entity of a potential claim. Like the LD 0274, the Notice of Claim requires the claimant to provide personal information, details about the incident, and the nature of the claim. Both forms emphasize the importance of including specific information to ensure proper processing. The Notice of Claim typically has a deadline for submission, similar to the six-month timeframe specified in the LD 0274, reinforcing the urgency of timely filing.

Another document that shares similarities with the LD 0274 is the Personal Injury Claim form. This form is specifically designed for individuals seeking compensation for injuries sustained due to another party's negligence. Much like the LD 0274, it requires detailed descriptions of the incident and the injuries sustained. Both forms necessitate the submission of supporting documentation, such as medical records or repair estimates, to substantiate the claims being made.

The Vehicle Accident Report is also comparable to the LD 0274 form. This report is typically filed with local law enforcement following an accident. It captures essential details about the incident, including the date, time, and location, similar to the information required in the LD 0274. Both documents serve to establish a record of the incident, which can be crucial for processing claims and determining liability.

The Claim for Damages form is another document that aligns with the LD 0274. This form is used to request compensation for damages incurred, whether to property or personal injury. Like the LD 0274, it requires claimants to provide specific details about the incident and the damages suffered. Both forms aim to facilitate the claims process by gathering necessary information upfront, allowing for a more efficient review and resolution.

Additionally, the Tort Claim form is similar in purpose and structure to the LD 0274. Tort claims are filed when an individual believes they have suffered harm due to the actions of a government entity. Both forms require claimants to outline the circumstances surrounding the incident, including the alleged negligence of the government entity involved. This similarity highlights the legal framework surrounding claims against government bodies and the importance of adhering to specific filing requirements.

Lastly, the Insurance Claim form mirrors the LD 0274 in that it is used to seek compensation for losses due to an incident, such as an accident. This form requires detailed information about the incident, the damages incurred, and the claimant's insurance coverage. Both forms emphasize the need for thorough documentation and timely submission to ensure the claim is processed effectively. The structure and information required in both documents serve to protect the rights of claimants while providing a clear path for resolution.

Dos and Don'ts

When filling out the LD 0274 form, it’s essential to follow specific guidelines to ensure your claim is processed smoothly. Here are four important do's and don'ts:

  • Do complete the form electronically, or print it clearly using a typewriter.
  • Do sign and date the form. Unsigned and undated forms will not be accepted.
  • Don't leave any sections blank. Incomplete forms may delay processing or result in rejection.
  • Don't forget to provide supporting documentation, such as police reports or estimates, as required.

Misconceptions

Understanding the LD 0274 form can be challenging. Here are ten common misconceptions about this form, along with clarifications:

  1. It can only be used for vehicle accidents. Many people believe this form is limited to vehicle-related incidents. In fact, it can be used for personal injury, property damage, or damage to growing crops.
  2. All claims are automatically accepted. Some think that submitting the form guarantees approval. However, claims can be denied based on various factors, including insufficient evidence or failure to meet deadlines.
  3. You have unlimited time to file a claim. Many assume there is no time limit. In reality, you must file within six months of the incident date.
  4. Only individuals can file a claim. Some believe that only individuals can use this form. In truth, businesses and organizations can also submit claims.
  5. Submitting the form is enough to get compensation. People often think that just filling out the form will lead to payment. However, you must provide supporting documentation, such as estimates or receipts.
  6. Claims can be filed for any amount. Some individuals think they can claim any amount. This form is specifically for claims of $10,000 or less.
  7. Unsigned forms will still be processed. Many believe that an unsigned form will be accepted. Unfortunately, unsigned and undated forms are not accepted.
  8. Providing personal information is mandatory. Some think they must provide all requested personal information. While it is encouraged for processing, some information can be voluntary.
  9. Filing a claim is a simple process. Many underestimate the complexity of filing. The process requires detailed information and can be time-consuming.
  10. Once submitted, you will receive immediate feedback. Some expect quick responses. However, processing claims can take time, and you may not hear back right away.

Understanding these misconceptions can help you navigate the claims process more effectively. Be sure to read all instructions carefully and provide complete information to avoid delays.

Key takeaways

  • Complete All Sections: Ensure every part of the LD 0274 form is filled out. Missing information can lead to delays or rejection of your claim.
  • Timely Submission: You have six months from the date of the incident to file your claim. Mark your calendar to avoid missing this deadline.
  • Provide Detailed Information: Include specific details about the incident, such as time, date, and location. The more information you provide, the easier it will be for the Department of Transportation to process your claim.
  • Attach Supporting Documents: When applicable, include police reports, photographs, and estimates or receipts for damages. These documents strengthen your claim and provide necessary context.