Form Center

2. All claims of personal injury or property damage against the Cosumnes Community Services District must be filed with the Clerk of the Board. Claimants must complete a claim form and submit the completed form with all attachments either online, in person or via mail. Staff recommend the claimants keep a copy of all submitted documents.
   
   Claims received by the Clerk of the Board will be forwarded to the District’s insurance provider. All claimants are then notified what action will be taken within 45 days (plus additional if claim was mailed), or otherwise notified as to the claim itself. If the claim is recommended for denial, you will be sent a letter notifying you of the action taken, and any further action necessary or available to you. Please note all claims are public record.
   
   Questions? Please contact the Clerk of the Board by phone at (916) 405-5600.
4. INSTRUCTIONS
   Complete the following information and click submit when done.
6. SECTION 1: CLAIMANT INFORMATION
8. First Name*
9. Last Name*
11. Address*
13. City*
14. State*
15. Zip*
17. Phone Number*
18. Email Address
20. Claimant Birthdate
21. Month*
    -- Select One --01 - January02 - February03 - March04 - April05 - May06 - June07 - July08 - August09 - September10 - October11 - November12 - December
22. Date*
    -- Select One --12345678910111213141516171819202122232425262728293031
23. Year*
25. SECTION 2: CLAIM INFORMATION
27. Date of Incident/Accident
    Date of Incident/Accident
28. Date injuries, damages, or losses were discovered
    Date injuries, damages, or losses were discovered
30. Location of Loss
    (Please specify in as much detail as possible. Ex: 5 feet east of west corner of Elmira Road and Peabody)
32. What did entity or employee do to cause this injury, damage, or loss?
34. What specific injury, damages, or other losses did you incur?
36. What amount of money is claimant seeking or, if the amount is in excess of $10,000, which is the appropriate court of jurisdiction. Note: If Superior and Municipal Courts are consolidated, you must represent whether it is a “limited civil case” [see Government Code 910(f)]
38. How was this amount calculated? (Itemize and attach bills, repair estimates, receipts, etc. If claim is for vehicle damage, obtain and attach two (2) repair estimates)
40. What is your basis for claiming the District or District employee(s) are the cause of injury, damages or loss?
42. What are the name(s) of District employee(s) whom you allege caused your injury, damages or loss, if known?
44. Name, address and phone number of any witnesses who can substantiate your claim.
46. Any additional information that you believe might be helpful to the District in considering this claim.
48. ADD ATTACHMENTS

    You may upload up to three (3) files to support your claim (photos, receipts, estimates, etc.).

    1. Click “Choose File” below.
    2. Select the file from your computer.
    3. Repeat to add up to three total attachments.
    4. Make sure each file appears in the list before you submit your claim.

    Accepted formats: PDF, JPG, PNG, DOCX
    Max size: 5 MB per file

50. Attachment #1:
52. Attachment #2:
54. Attachment #3:
56. SECTION 3: NOTICE AND COMMUNICATIONS
    All notices and communications with regard to this claim will be directed to the Claimant shown in Section 1 above unless you complete the following to identify to whom further communication should be directed.
58. First Name
59. Last Name
61. Address
63. City
64. State
65. Zip Code
67. Phone Number
68. Email Address
70. Relationship to Claimant
72. SUBMIT REQUEST
    Section 72 of the Penal Code provides that, “every person who, with intent to defraud, presents for allowance or for payment to any State Board or Officer, or to any county, town, city, district, board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony.”
74. Date of Request
    Date of Request
76. Signature of person making the request
Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit

* indicates a required field