Claim Instructions and Information

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Revised 03/15/2016

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CIVIL DIVISION 77 N. Front Street Columbus, Ohio 43215-9013 614-645-7385 Fax: 614-724-6503 CLAIMS DIVISION 77 N. Front Street Columbus, Ohio 43215-9013 614-645-7385 Fax: 614-645-2291 RICHARD C. PFEIFFER, JR. CITY ATTORNEY COLUMBUS, OHIO PROSECUTOR DIVISION 375 S. High Street Columbus, Ohio 43215-4530 614-645-7483 Fax: 614-645-8902 REAL ESTATE DIVISION 77 N. Front Street Columbus, Ohio 614-645-7712 Fax:614-645-3913

Claim Instructions and Information

Please find enclosed the City of Columbus Claim form. Please complete the form, sign in front of a notary and return the form to the proper department. It is important to note that the City will not open a claim and an investigation will not begin until a completed claim form is received.

If a portion of the form does not apply to your particular situation, please write not applicable or n/a. All details, dates, times and location provided must be accurate.

If you are not sure whether the City is liable for your injury or damage, please submit your claim to the City Department in question and the Department will contact you.

Generally, the City of Columbus is not liable in damages in a civil action for injury, death, or loss to person or property allegedly caused by any act or omission of the City or its employees. There are some exceptions. The City may be liable for: (1) the negligent operation of a motor vehicle, unless police, fire or EMS are responding to an emergency; (2) the negligent performance of proprietary functions; (3) the negligent failure to keep public roads in repair and negligent failure to remove obstructions; (4) the negligence of its employees within or on the grounds of, and due to physical defects within or on the grounds of, buildings; or (5) when the Ohio Revised Code imposes liability. If one of these exceptions applies, you must file a claim with your insurance company first. The Ohio Revised Code limits the amount of money a city may pay. Any amount of money you received, or should receive even if you haven’t, is deducted from the amount owed to you by the city. The City would then be responsible for such items as your deductible.

Ohio Revised Code, 2744.05, states that no insurer or other person is entitled to bring an action under a

subrogation provision of insurance or other contract against a political subdivision with respect to those benefits.

Attachment Checklist-Please read before submitting your claim. This information is necessary in order to open a proper investigation. All of the above information is necessary to start the investigation. Liability cannot be determined until a thorough investigation of your claim is completed.

If claiming vehicle damage, you need to provide:

Declaration Page of car insurance policy showing deductible, copy of title, registration or lease contract, two written estimates, police report (if applicable), current mileage and photographs of vehicle damage. If you are claiming tire damage, the age of the tire is required.

If claiming personal injury:

Copies of all medical reports including doctor bills, hospital bills and pharmacy receipts

If claiming other property damage:

A copy of the homeowner’s insurance policy that includes the deductible amount is required. A separate itemized list of property damages with a description of each item, serial number, quantity lost,

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Once you have collected all of the required information and completed the claimant statement form, please forward the information to the appropriate Department to begin the investigation process. If the City is liable, the City will issue you a check. This process may take 4 to 6 weeks. You will be asked to sign a Release and Agreement and a W-9 form, and return them to the City Department that is handling your claim.

Potholes

With respect to any damage your vehicle may have sustained, we must inform you that the City, by statute, has certain immunities from liability for damages of this nature. As stated above, Ohio Revised

Code Section 2744.05 addresses these immunities. In general, in order to recover in a suit involving

damage proximately caused by roadway conditions, including potholes, the party claiming damage must prove that either: 1) the City had actual or constructive notice of the pothole and failed to respond in a reasonable amount of time, or responded in a negligent manner, or 2) that the City, in a general sense, maintains its roadways negligently.

Hopefully, this has answered all of your questions; however, if you still need assistance, you can contact the City Department that will handle your claim or the City Attorney’s office and speak to one of the individuals listed below.

Katie Aukerman Legal Investigator (614) 645-8603 or ksaukerman@columbus.gov Nicole Mullane Legal Investigator (614) 645-7681 or nmmullane@columbus.gov

If it is after normal working hours you may contact the 3-1-1 Call Center @ (614) 645-3111 or go to

www.311.columbus.gov. The call center hours are Monday –Friday 7:00am to 6:00pm. If this is an emergency please dial 9-1-1 to contact the police.

Building & Zoning Services 757 Carolyn Avenue

Columbus, Ohio 43224 614-645-7898 Linda Guyton lkguyton@columbus.gov Development Housing, Building & Code

Enforcement

50 W. Gay Street 3rd Floor

Columbus, OH 43215

614-645-6130 Chris Swauger ciswauger@columbus.gov

Fire 3675 Parsons Avenue

Columbus, OH 43207 614-645-6011 Scott Marburger smmarburger@columbus.gov Police/ Impound Lot 77 N. Front Street

Columbus, OH 43215 614-645-7681 Nicole Mullane nmmullane@columbus.gov

Pot Holes, Refuse, Transportation, Streets, Signs, Construction

Contact by phone first 50 W. Gay Street Columbus, Ohio 43215

614-645-3111 Call Center

You must contact the 311 call center & place a service claim. A Claim Investigator will contact you after the service claim is received.

Recreation and Parks 1111 E. Broad Street

Columbus, OH 43205 614-645-1491 Connie Warner cgwarner@columbus.gov Water, Power, Sewers and Drains 910 Dublin Road

Columbus, OH 43215 614-645-6261

Angie Courtright Shelly Seniuk

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City of Columbus

Claimant Statement Form

STATE

____VEHICLE ____INJURY

PROPERTY INSURANCE COMPANY DEDUCTIBLE AMOUNT

FOR DAMAGE CLAIMS OTHER THAN VEHICLE DAMAGE

WHAT IS DAMAGED CAUSE OF DAMAGE & HOW IT WAS DAMAGED

AGE OF DAMAGED PROPERTY: REPLACEMENT, RESTORATION OR REPAIR COST (IF MORE THAN ONE ITEM, YOU MUST FILL OUT THE ITEMIZED PROPERTY CLAIM FORM):

TWO REPAIR ESTIMATES (ATTACH ESTIMATE DOCUMENTS) (1) $ (2) $ # OF PEOPLE IN YOUR VEHICLE: WHO:

DEDUCTIBLE AMOUNT AUTO INSURANCE COMPANY MEDICAL INSURANCE COMPANY

FOR VEHICLE DAMAGE CLAIMS OR AUTOMOBILE ACCIDENTS

VEHICLE MAKE/MODEL OWNER'S NAME DRIVER'S NAME

YEAR LICENSE PLATE # MILEAGE

OWNER'S ADDRESS & PHONE DRIVER'S ADDRESS & PHONE WITNESS NAME:

WITNESS NAME:

PHONE:

PHONE: ADDRESS:

ADDRESS: IF YES, WHAT POLICE DEPT. & REPORT #? IF NO, WHY?

INCIDENT DATE INCIDENT TIME ADDRESS OF INCIDENT

DETAILED DESCRIPTION OF INCIDENT

NAME OF EMPLOYEE (IF KNOWN): CITY DEPARTMENT THAT WAS INVOLVED:

TYPE OF DAMAGE: ____ OTHER PROPERTY POLICE REPORT MADE? YES NO Hours of Operation: 8am to 5pm Weekdays

NAME

STREET ADDRESS EMAIL ADDRESS

BIRTH DATE HOME PHONE WORK PHONE

CITY ZIP

EMPLOYER NAME

YES NO

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Claimant Statement Form

DATE

day of 20 .

FOR PERSONAL INJURY CLAIMS

NATURE & EXTENT OF YOUR INJURY

HEALTH INSURANCE COMPANY DEDUCTIBLE AMOUNT HOSPITAL TRANSPORTED TO:

SWORN TO BEFORE ME and subscribed in my presence this ,

NOTARY PUBLIC, STATE OF OHIO

I further state that I am not entitiled to receive additional reimbursement for these injuries and/or damages from any other source other than the City of Columbus and that the claim(s) arising from these injuries and/or damages are a direct result of this incident.

CLAIMANTS SIGNATURE

The Ohio Revised Code, Section 2744.05 outlines limitations of damages awarded for claims against political subdivisions. If a claimant receives or is entitled to receive benefits from insurance policy or policies, that amount will be deducted from any award the polictial subdivision may condider paying. This includes Medicaid, Medicare and auto policIES. You must file a claim with your insurance company prior to filing a claim with the City of Columbus.

PROVIDE DATE AND NATURE OF ANY PRIOR INJURIES ATTENDING PHYSICIAN NAME ATTENDING PHYSICIAN ADDRESS

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City of Columbus

Claimant Statement Form

Property Description (Including brand name and serial #)

Quantity Date purchased or Age

Purchase Price Replacement, Restoration or Repair cost

Itemized Property Claim Form

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References

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