This claims procedure is intended to (1) encourage the early detection and correction of dangerous conditions; and, (2) to encourage claimants and the City to fully understand the merits of claims, and to compensate those that should be compensated - without going to the time and expense of litigation.
Any person having a claim against the City of Hillsboro which could give rise to an action brought under the Kansas Tort Claims Act shall file a written notice, on a claim form that has been approved by the Governing Body, before commencing such action. This notice shall be filed with the city clerk or Governing Body of the City of Hillsboro and shall contain the following:
1. The name and address of the claimant, and the name and address of the claimant’s attorney, if any;
2. A concise statement of the factual basis of the claim, including the date, time, place and circumstances of the act, omission, or event complained of;
3. The name and address of any public officer or employee involved, if known;
4. A concise statement of the nature and the extent of the injury claimed to have been suffered; and,
5. A statement of the amount of monetary damages that is being requested.
In the filing of a notice of claim, substantial compliance with the above provisions and requirements shall constitute valid filing of a claim. The contents of such notice shall not be admissible in any subsequent action arising out of the claim. Once notice of the claim is filed, no action shall be commenced until after the claimant has received notice from the City that it has denied the claim or until after 120 days has passed following the filing of the notice of claim, whichever occurs first. A claim is deemed denied if the City fails to approve the claim in its entirety within 120 days unless the interested parties have reached a settlement before the expiration of that period. No person may initiate an action against the City unless the claim has been denied in whole or part. Any action brought pursuant to the Kansas Tort Claims Act shall be commenced within the time period provided for in the code of civil procedure or it shall be forever barred, except that if compliance with the above provisions would otherwise result in the barring of an action, such time period shall be extended by the time period required for compliance with these provisions.
City Employees shall report to the City Clerk any incidents which could result in possible liabilities at the earliest opportunity so that evidence can be preserved, if appropriate the City police shall take photographs and preserve other important facts or evidence.
CASE NO. ____________
City of
Hillsboro, Kansas CLAIMANT __________
DAMAGES/INJURY CLAIM FORM DATE
FILED ___________
This form must be
completed by all persons making a claim against the city for personal injuries
or property damage. The term “incident” refers to the circumstances you allege
to be an accident which caused injury or damages to you.
1. NAME/ADDRESS OF
CLAIMANT 2.
CLAIM FILED WITH:
(Full Name, Street
Address, Telephone Number) ___________________________________________
___________________________________________ 3. AGE OF CLAIMANT:
_________________
___________________________________________ 5. NAME/ADDRESS OF CITY
EMPLOYEE
4. NAME/ADDRESS OF
SPOUSE, IF ANY INVOLVED
IN INCIDENT
___________________________________________ ______________________________________
___________________________________________ ______________________________________
6. PLACE OF INCIDENT DAY/DATE
OF INCIDENT
__________________________________________ : (am) (pm) _______________
8. AMOUNT OF CLAIM:
Property Damage:
$_______________
Personal Injury:
$_______________
Total:
$________________
9. DESCRIPTION OF
INCIDENT: (State below, in detail, all known facts and
circumstances relating to the damage or injury to persons and property involved
and the case thereof) ____________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
10. PROPERTY DAMAGE
a. Name/Address of Owner,
if other than Claimant. ________________________________________
__________________________________________________________________________________
b. Describe kind and
location of property and nature and extent of damage. _____________________
__________________________________________________________________________________
11. PERSONAL INJURY
a. State nature and extent
of injury which forms the basis of this claim. ________________________
_________________________________________________________________________________
b. If medical treatment
was sustained as a result of the incident, provide names of physician and
medical treatment
facility. ____________________________________________________________
12. WITNESSES
(Name/Address of any Eyewitnesses 13.
INSURANCE COVERAGE
to incident known to Claimant) a.
Do you carry Accident Insurance?_________
___________________________________________ If yes, give Name/Address
of Insurance
___________________________________________ Company
______________________________
14.CLAIMANT’S REPRESENTATIVE ______________________________________
If you have
authorized any person to act on your behalf Insurance
Policy No. ______________
in settling this
claim, state that person’s b. Have you filed a claim with
your insurance
Name:
_______________________________________ carrier
as a result of this incident? ___________
Address:
_____________________________________ If
yes, is it full coverage or deductible?
_____________________________________________ _____________ If deductible: $____________
Phone:
_________________________________ c.
If claim has been filed with your carrier, what
Relationship to
Claimant: __________________ action
has your insurer taken or proposed to
Does notice by the
City to the above person of actions take
with regard to your claim? _____________
your claim constitute
notice to you? ______________ ______________________________________
I
certify that the amount of claim covers only damages and injuries caused by the
incident above and agree to accept said amount in full satisfaction and final
settlement of this claim.
15. SIGNATURE OF
CLAIMANT 16.
DATE
______________________________________ ____________________________________
INSTRUCTIONS
a. All items on this
form must be completed. Insert the word “NONE” where applicable.
b. Claims for damages
to or for loss or destruction of property or for personal injury against a city
must be submitted in writing to the city (L. 1987, Ch. 353, Sec. 9)
c. Following receipt
of this claim, the city has 120 days to approve or otherwise settle it.
d. Unless the city
denies all or part of your claim, you may not commence a lawsuit against the
city under the Kansas Tort Claims Act. You claim is deemed denied if no action
is taken within 120 days following the filing of your claim.
e. If you do not
fully understand your rights and duties in making this claim, you should
consult an attorney.