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Claims Form

  1. All claims of personal injury or property damage against the Cosumnes Community Services District must be filed with the Clerk of the Board. Claimants must complete a claim form and submit the completed form with all attachments either online, in person or via mail. Staff recommend the claimants keep a copy of all submitted documents.

    Claims received by the Clerk of the Board will be forwarded to the District’s insurance provider. All claimants are then notified what action will be taken within 45 days (plus additional if claim was mailed), or otherwise notified as to the claim itself. If the claim is recommended for denial, you will be sent a letter notifying you of the action taken, and any further action necessary or available to you. Please note all claims are public record.

    Questions? Please contact the Clerk of the Board by phone at (916) 405-5600.

  2. INSTRUCTIONS

    Complete the following information and click submit when done.

  3. SECTION 1: CLAIMANT INFORMATION

  4. Claimant Birthdate

  5. SECTION 2: CLAIM INFORMATION

  6. (Please specify in as much detail as possible. Ex: 5 feet east of west corner of Elmira Road and Peabody)

  7. SECTION 3: NOTICE AND COMMUNICATIONS

    All notices and communications with regard to this claim will be directed to the Claimant shown in Section 1 above unless you complete the following to identify to whom further communication should be directed.

  8. SUBMIT REQUEST

    Section 72 of the Penal Code provides that, “every person who, with intent to defraud, presents for allowance or for payment to any State Board or Officer, or to any county, town, city, district, board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony.”

  9. Leave This Blank:

  10. This field is not part of the form submission.