Notice Of Tort Claim Form
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1
2NOTICE OF TORT CLAIM
OKLAHOMA MUNICIPAL ASSURANCE GROUP (OMAG) – MUNICIPAL LIABILITY PROTECTION PLAN
A. CLAIMANT REPORT
To the ___________________________________________________________
Public entity you are filing the claim against.
PLEASE PRINT OR TYPE AND SIGN
IMPORTANT NOTICE: This notice will be sent to OMAG Claims Dept. for investigation. You may expect them to contact you.
CLAIMANT(S)__________________________________
CLAIMANT(S) SOCIAL SECURITY NO._________________________
ADDRESS______________________________________
CLAIMANT(S) DATE OF BIRTH ____________________ Circle: M F
_______________________________________________
PHONE: HOME (___)
BUS. (___)________________
(Continue on another sheet if needed
(Exact Date Required)
1.
DATE AND TIME OF INCIDENT
(___) a.m. (___) p.m.
for any information requested)
2.
LOCATION OF INCIDENT________________________________________________________________________________
3.
DESCRIBE INCIDENT ___________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
4.
LIST ALL PERSONS AND/OR PROPERTY FOR WHICH YOU ARE CLAIMING DAMAGES:
BODILY INJURY: WAS CLAIMANT INJURED? YES___ NO___ If yes, complete this section
Describe injury ________________________________________________________________________________________
WERE YOU ON THE JOB AT THE TIME OF INJURY? YES___ NO___ If so, please provide Employer info.
_____________________________________________________________________________________________________
Employer’s Name
Address
Phone
ALL MEDICAL BILLS (attach copies)
$__________________
LIST OTHER DAMAGES CLAIMED
$__________________
MEDICARE/MEDICAID/SOCIAL SECURITY DISABILITY:
Is there any Social Security Disability involvement ___Yes ___ No
Has any medical bill been paid or will be paid by Medicare/Medicaid? ___Yes ___No. If so, list Medicare/Medicaid Number.
Medicare/Medicaid Number ____________________
If the City is responsible for such bills, the City must report any settlement to Medicare/Medicaid.
I understand that the information requested is to assist the requesting insurance information arrangement to accurately
coordinate benefits with Medicare/Medicaid and to meet its mandatory reporting obligation under Medicare Secondary Payer
Act 42 U.S.C§1395y.
_________________________________________
____________________________________________________
Medicare/Medicaid Beneficiary Name (please print)
Medicare/Medicaid Beneficiary Name Signature
PROPERTY DAMAGE: Proof that you are the owner of the vehicle or property allegedly damaged as specified in your claim will be
required.
VEHICLE YEAR____________ MAKE ________________________________ MODEL____________________________
NOTE: If damage is to a vehicle, a photocopy of your motor vehicle title is required.
IF NOT A VEHICLE, DESCRIBE PROPERTY AND LOSS____________________________________________________
_____________________________________________________________________________________________________
PROPERTY DAMAGE (Attach repair bills or estimates if available) $_________________________
LIST OTHER DAMAGES CLAIMED $_________________________
5. NAME OF YOUR INSURANCE CO.
POLICY NO.
AMOUNT CLAIMED
AMOUNT RECEIVED
_______________________________
__________________ $_________________
$__________________
6. The names of any witnesses known to you:
__________________________________________________________________________________________________
Name
Address
Phone Number
__________________________________________________________________________________________________
Name
Address
Phone Number
STATE THE EXACT AMOUNT OF COMPENSATION YOU WOULD ACCEPT AS FULL SETTLEMENT ON THIS CLAIM.
TOTAL CLAIM………… $_________________
________________________________________________________________________________________________________
SIGNATURE(S)
DATE
CONTINUE ON THE BACK
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