Claim Report Form
1) The Sacramento Regional Transit District is hereby notified that a claim for damages, as set forth below, is presented to the District:
Download PDF Form
Name
(Required)
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Home Phone
(Required)
Birth Date
(Required)
MM slash DD slash YYYY
Work Phone
Soc. Sec. #
2) The address to which notices concerning this claim are to be sent is:
Name
(Required)
Address
(Required)
Phone
(Required)
City
(Required)
State
(Required)
Zip
(Required)
3) Description of Incident:
Vehicle(s) Involved
(Required)
Bus
Light Rail
Other
Date
(Required)
MM slash DD slash YYYY
Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
RT Vehicle #
(Required)
Route#
(Required)
Name of RT Employee (If known)
OR Description of RT Employee
Location:
Street or Light Rail Station
(Required)
Direction of Travel
(Required)
Nearest Intersection
(Required)
City
(Required)
Describe what happened
(Required)
4) Describe injuries and/or property damages sustained as a result of this incident:
Describe injuries and/or property damages sustained as a result of this incident:
(Required)
5) Statement of Damages:
List any and all costs incurred to date, and estimates of any future costs as a result of this incident. Attach receipts, if available:
Amount
a)
Amount
b)
$
c)
$
d)
Untitled
e)
$
e)
$
Total Amount Claimed:
6) DECLARATION UNDER PENALTY OF PERJURY:
I have read the matters and statements made herein regarding this claim; and I know the same to be true of my own knowledge, except as to those matters stated, upon information and belief and as to such matters I believe the same to be true:
I certify under penalty of perjury that the foregoing is true and correct.
Executed this
Date
(Required)
MM slash DD slash YYYY
City
(Required)
State
(Required)
Claimant’s Signature
(Required)
Type or Print Claimant’s Name
(Required)