Palisades Fire – Claim Form

Please complete and submit the following Los Angeles Claim for Damages by May 1, 2025.  California law requires that this form must be completed, signed, and submitted to the City of Los Angeles before we can file a lawsuit on your behalf.

CLAIMANT INFORMATION:

Name(Required)

First Last

Date of Birth

Email Address

Phone Number(Required)

Address(Required)

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Indicate if claim notices or communications should be sent to someone other than the claimant (e.g. attorney or insurance representative). If checked, complete the information below:

Yes

Attorney Name(Required)

Relationship to Claimant(Required)

Attorney Email

Attorney Phone(Required)

Address(Required)

Street Address Address Line 2 City VirginiaAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

FACTUAL ALLEGATIONS:

How did damage or injury occur?(Required)

Claimant suffered injuries as a result of the Palisades Fire. Claimant seeks to file a lawsuit against the City of Los Angeles and LADWP for these injuries.

Please provide the date and time of the damage or injury(Required)

Where did damage or injury occur?(Required)

Why do you claim the City of Los Angeles is responsible for your damage or injury?

Claimant seeks to pursue certain claims against 1) the City of Los Angeles and 2) the City of Los Angeles, acting by and through the Los Angeles Department of Water and Power (LADWP) for various injuries related to the Palisades Fire, which began on January 7, 2025 and burned for weeks thereafter. Los Angeles and LADWP are already on notice of various claims against them relating to the Palisades Fire (see, Pratt, et al. v. City of Los Angeles, et al.; Case No.: 25STCV01720). Claimant incorporates the common liability allegations from the Pratt case as if set forth fully herein. In short, City of Los Angeles and LADWP had a duty to properly construct, inspect, maintain, and operate their water supply systems. The Palisades Fire was an inescapable and unavoidable consequence of the water supply system operated by City of Los Angeles and LADWP as it was planned and constructed. The system necessarily failed, and this failure was a substantial factor in causing claimant's injuries.

WITNESSES AND INVOLVED PARTIES:

Give the names of City employees and their contact information, City vehicle license plate numbers, and the City department or bureau responsible for the act or omission you claim caused the damage or injury, if known.(Required)

Investigation is still ongoing. Claimant understands that various entities are investigating the Palisades Fire and a report as to causation will be forthcoming.

Did you report the act or omission? If so, please identify who you reported it to, provide their contact information and any report, service or claim numbers.

Please list the names and contact information for Witnesses Doctors and Hospitals

DAMAGES:

What damage or injuries do you claim resulted?(Required)

What is the total amount of your claim(Required)

Property Damages(Required)

Yes

No

Property Damages Amount(Required)

Bodily Injury(Required)

Yes

No

Bodily Injury Amount(Required)

Other(Required)

Yes

No

Other (specify)(Required)

Other Amount(Required)

INSURANCE:

If you had insurance at the time of the act or omission, please give the name and contact information for your insurance company, handling representatives and any amounts paid:

Signature of Claimant or Person Filing on Claimant’s Behalf(Required)

Print Name(Required)

Date(Required)

MM slash DD slash YYYY

Relationship to Claimant(Required)

Submit

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