31. Filing Claim Against the City for Damages/Injury
PURPOSE
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.
POLICY
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.