COPYGOVERNMENT TORT CLAIM DANGEROUS CONDITION OF PUBLIC PROPERTY TO: Office of the City Clerk City of [CITY NAME] [ADDRESS] CLAIMANT INFORMATION: Name: [YOUR FULL LEGAL NAME] Address: [YOUR STREET ADDRESS] [CITY, STATE ZIP] Phone: [YOUR PHONE NUMBER] Email: [YOUR EMAIL] DATE AND LOCATION OF INCIDENT: Date: [DATE OF INJURY] Time: Approximately [TIME] Location: [PRECISE LOCATION - e.g., "Sidewalk on the east side of Main Street, approximately 50 feet south of the intersection with Oak Avenue, in front of 123 Main St."] DESCRIPTION OF DANGEROUS CONDITION: The sidewalk at this location contained a raised concrete section where tree roots from the adjacent city-owned tree had displaced the pavement. The height differential between the two sidewalk sections was approximately [X] inches. There were no warning signs, cones, paint markings, or other indicators alerting pedestrians to this hazard. The raised section was located in a high-traffic pedestrian area near [describe nearby businesses, transit stops, etc.]. DESCRIPTION OF INCIDENT: On [DATE], at approximately [TIME], I was walking [direction] on the sidewalk when my [foot] caught on the raised concrete section. I was unable to recover my balance and fell [forward/to the side], striking the pavement with my [hands/knees/head/etc.]. I was using the sidewalk in a normal manner, walking at a normal pace, and was paying reasonable attention to my surroundings. The hazard was not visible due to [shadows/lighting/color of concrete matching surroundings/etc.]. INJURIES SUSTAINED: As a result of this fall, I sustained the following injuries: - [Injury #1, e.g., "Fractured left wrist (distal radius fracture) requiring open reduction internal fixation surgery"] - [Injury #2, e.g., "Torn rotator cuff in right shoulder"] - [Injury #3, e.g., "Multiple contusions and abrasions to knees and hands"] - [Injury #4, e.g., "Ongoing pain and limited range of motion"] MEDICAL TREATMENT: I received the following medical treatment: - Emergency room visit at [Hospital Name] on [Date] - Orthopedic surgery by Dr. [Name] on [Date] - Physical therapy at [Provider] from [Date] to [present/Date] - [Additional treatment] I continue to receive treatment and my prognosis is [describe]. DAMAGES CLAIMED: Medical expenses incurred to date: $[AMOUNT] Estimated future medical expenses: $[AMOUNT] Lost wages (past): $[AMOUNT] Lost earning capacity (future): $[AMOUNT] Pain and suffering: $[AMOUNT] Other damages [specify]: $[AMOUNT] TOTAL DAMAGES: $[TOTAL] [If over jurisdictional limit:] Claimant reserves the right to amend this claim to seek damages in excess of $[amount] as discovery and treatment continue. NOTICE TO PUBLIC ENTITY: Upon information and belief, the City of [CITY NAME] had actual and/or constructive notice of this dangerous condition: - The condition existed for a substantial period of time - The location is subject to regular inspection - Prior complaints may have been filed with the City - The condition was open and obvious to inspection WITNESSES: [If known:] Name: [WITNESS NAME] Phone: [WITNESS PHONE] Address: [WITNESS ADDRESS] [If none known:] "No witnesses identified at this time. Investigation continuing." PUBLIC EMPLOYEES INVOLVED: [If known - or:] "Unknown at this time. Claimant requests disclosure of any city employees responsible for sidewalk maintenance and inspection in this area." VERIFICATION: I declare under penalty of perjury under the laws of the State of [STATE] that the foregoing is true and correct. Executed on [DATE] at [CITY], [STATE]. _________________________________ [YOUR SIGNATURE] [YOUR PRINTED NAME] Claimant