5. Description of property damaged:

6. Owner of property damaged:

7. Location of property damaged:

8. Description of personal injury (if there was no personal injury, state

"NONE"):

9. Name of any other person injured:
Address of injured person:_____

1 0. Names and addresses of witnesses, doctors, hospitals, etc.:

NAME ADDRESS TELEPHONE

(1)

(3)

1 1 . Amount of reimbursement claimed as damages with computation and supporting bills, receipts, or estimates of cost: (Please attach supporting documents to this form)

12. Any additional information that might be helpful in considering claim:

WARNING! IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM!

(Penal Code 72: Insurance Code 556)

I have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters stated upon information or 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.

SIGNED THIS DAY OF 20 TIME:

CLAIMANT'S SIGNATURE