Fillable Claim For Damage, Injury, Or Death (Page 2 of 2) in pdf

PRIVACY ACT NOTICE

This Notice is provided in accordance with the Privacy Act, 5 U.S.C. 552a(e)(3), and B. Principal Purpose: The information requested is to be used in evaluating claims.

concerns the information requested in the letter to which this Notice is attached.

C. Routine Use: See the Notices of Systems of Records for the agency to whom

A. Authority: The requested information is solicited pursuant to one or more of the

you are submitting this form for this information.

following: 5 U.S.C. 301, 38 U.S.C. 501 et seq., 28 U.S.C. 2671 et seq., 28 C.F.R.

D. Effect of Failure to Respond: Disclosure is voluntary. However, failure to supply

Part 14.

the requested information or to execute the form may render your claim "invalid".

INSTRUCTIONS

Complete all items - insert the word NONE where applicable

A CLAIM SHALL BE DEEMED TO HAVE BEEN PRESENTED WHEN A FEDERAL

PROPERTY, PERSONAL INJURY, OR DEATH ALLEGED TO HAVE OCCURRED BY

AGENCY RECEIVES FROM A CLAIMANT, HIS DULY AUTHORIZED AGENT, OR

REASON OF THE INCIDENT. THE CLAIM MUST BE PRESENTED TO THE

LEGAL REPRESENTATIVE AN EXECUTED STANDARD FORM 95 OR OTHER

APPROPRIATE FEDERAL AGENCY WITHIN TWO YEARS AFTER THE CLAIM

- - - -

WRITTEN NOTIFICATION OF AN INCIDENT, ACCOMPANIED BY A CLAIM FOR

ACCRUES.

MONEY DAMAGES IN A SUM CERTAIN FOR INJURY TO OR LOSS OF

- - - - -

Any instructions or information necessary in the preparation of your claim will be

furnished, upon request, by the office indicated in Item #1 on the reverse side.

Complete regulations pertaining to claims asserted under the Federal Tort Claims

Act can be found in Title 28, Code of Federal Regulations, Part 14. Many agencies

have published supplemental regulations also. If more than one agency is involved,

please state each agency.

The claim may be filed by a duly authorized agent or other legal representative,

provided evidence satisfactory to the Government is submitted with said claim

establishing express authority to act for the claimant. A claim presented by an

agent or legal representative must be presented in the name of the claimant. If the

claim is signed by the agent or legal representative, it must show the title or legal

capacity of the person signing and be accompanied by evidence of his/her authority

to present a claim on behalf of the claimant as agent, executor, administrator,

parent, guardian or other representative.

If claimant intends to file claim for both personal injury and property damage,

claim for both must be shown in Item 12 of this form.

The amount claimed should be substantiated by competent evidence as follows:

(a)

In support of the claim for personal injury or death, the claimant should submit

a written report by the attending physician, showing the nature and extent of injury,

the nature and extent of treatment, the degree of permanent disability, if any, the

prognosis, and the period of hospitalization, or incapacitation, attaching itemized

bills for medical, hospital, or burial expenses actually incurred.

(b)

In support of claims for damage to property which has been or can be

economically repaired, the claimant should submit at least two itemized signed

statements or estimates by reliable, disinterested concerns, or, if payment has been

made, the itemized signed receipts evidencing payment.

(c)

In support of claims for damage to property which is not economically

repairable, or if the property is lost or destroyed, the claimant should submit

statements as to the original cost of the property, the date of purchase, and the

value of the property, both before and after the accident. Such statements should

be by disinterested competent persons, preferably reputable dealers or officials

familiar with the type of property damaged, or by two or more competitive bidders,

and should be certified as being just and correct.

(d)

Failure to completely execute this form or to supply the requested material

within two years from the date the allegations accrued may render your claim

"invalid". A claim is deemed presented when it is received by the appropriate

agency, not when it is mailed.

Failure to specify a sum certain will result in invalid presentation of your claim and

may result in forfeiture of your rights.

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing

data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any

other aspect of this collection of information, including suggestions for reducing this burden,

to Director, Torts Branch

and to the

Civil Division

Office of Management and Budget

U.S. Department of Justice

Paperwork Reduction Project (1105-0008)

Washington, DC 20530

Washington, DC 20503

INSURANCE COVERAGE

In order that subrogation claims may be adjudicated, it is essential that the claimant provide the following information regarding the insurance coverage of his vehicle or property.

15. Do you carry accident insurance?

Yes, If yes, give name and address of insurance company

(Number, street, city, State, and Zip Code)

and policy number.

16. Have you filed claim on your insurance carrier in this instance, and if so, is it full coverage or deductible?

17. If deductible, state amount

18. If claim has been filed with your carrier, what action has your insurer taken or proposes to take with reference to your claim?

(It is necessary that you ascertain these facts)

19. Do you carry public liability and property damage insurance?

Yes, If yes, give name and address of insurance company (Number, street, city, State, and Zip Code)

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