Form Tc-1 - Claim Against The State Of Nevada (2015)
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1
2CLAIM AGAINST THE STATE OF NEVADA
TO:
Claims Manager
Received By AG’s Office:
For AG’s Office Use Only:
Office of the Attorney General
Claim # ____________
Dir. ________________
DMV Legal/Tort Claims
X-Ref _____________
Emp. _______________
555 Wright Way
DOL ______________
State Veh Lic ________
Cat _______________
$ __________________
Carson City, NV 89711
B/A _______________
Adj ________________
(775) 684-1252 or (775) 684-1263
Agency ____________ due ________________
________________________________________
The following information is necessary to fairly evaluate your claim. Please provide complete information. If you need more
space, attach a separate sheet of paper. Additional evidence, such as photographs, police reports, etc., should be attached if
available. However, such additional evidence will not be returned. Keep copies for your records. PLEASE PRINT LEGIBLY
OR TYPE. You must sign the claim form.
YOU ARE NOT REQUIRED TO MAKE A CLAIM PRIOR TO FILING A LAWSUIT. THE MAKING OF A CLAIM WILL NOT STOP THE
RUNNING OF THE APPLICABLE STATUTE OF LIMITATIONS.
•
You are the claimant if you are making this claim for yourself.
•
Your Client is the claimant if you are an attorney making a claim on behalf of a client.
•
Your Company is the claimant if you are making a claim on behalf of a business.
•
The Insurance Company is the claimant if you represent an insurance company.
1.
CLAIMANT’S NAME __________________________________________________________________________________
ADDRESS __________________________________________________________________________________________
___________________________________________________________________________________________________
Daytime TELEPHONE NUMBER: (
) _________________________________________________________________
DATE OF BIRTH _______________________
2.
IF CLAIMANT IS A BUSINESS: Name of Employee involved in incident _________________________________________
Company Contact Person _______________________________________ Your Reference _________________________
3.
IF CLAIMANT IS AN INSURANCE COMPANY: Name of your “INSURED” _______________________________________
Claim Representative ____________________________________ Your Claim No. ________________________________
4.
IF YOU ARE REPRESENTED BY AN ATTORNEY: We will only communicate with you through your attorney.
It is not necessary to retain an attorney to file a claim; however, if you have an attorney for this claim, please provide the
following information:
Attorney’s Name ______________________________________________________________________________________
Firm’s Name
Tax I.D. Number
Address ____________________________________________________________________________________________
____________________________________________________________________________________________________
Phone Number: (
) ________________________________ File Reference _________________________________
5.
DATE AND TIME when the incident occurred: _______________________________________________________________
6.
Exact LOCATION where the incident occurred: ______________________________________________________________
7.
IF THIS IS AN AUTOMOBILE ACCIDENT, please supply the following information:
YOUR VEHICLE
Year _______ Make ________________________ Model _______________________ License Number _______________
STATE VEHICLE
Year _______ Make ________________________ Model _______________________ License Number _______________
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TC-1 (revised 11/15)
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Parent category: Legal