Notice of Claim

Forward to: (Public entity)

1. Claimant

____________________________________________________________ Last Name, First, Middle

_______________________

Date of Birth

____________________________________________________________

Street Address Mailing address if other then street

_____________________________________________________________ City, State , Zip Code

_____________________________________________________________ Social Security

If notice and correspondence in connection with this claim are to be sent to a person other than claimant, complete item #2.

2.

_____________________________________________________________

Name

_____________________________________________________________

Mailing Address

_______________________________

City, State, Zip Code

Relationship to claimant: Attorney at law or ________________________________________

Explain relationship

3. The occurrence or accident which gave rise to this claim:

a. __________________

Date

___________________

Time b. Describe the location or place of the accident of occurrence:

___________________________________________________________________ Municipality Exact place of the occurrence

c. Describe how the accident or occurrence happened: If a diagram will assist your explanation, please use the reverse side of this form.

___________________________________________________________________

d. State the name and address of the state agency or agencies that you claim caused your damage:

___________________________________________________________________

State the name of state employees whom you claim were at fault, including any information that will assist in identifying and locating them.

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ___________

e. State the negligence or wrongful acts of the state agency and state employees which caused your damage.

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ________________

f. State the name and address of all witnesses to the accident or occurrence.

___________________________________________________________________

g. State the name of all police officers and police departments who investigated the accident.

___________________________________________________________________

4. Damages

a. Claim for damages: ( ) Personal Injury ( ) Property Damage ( ) or

If other, explain in detail __________________________________________________________________________

b. If you claim personal injury, 1. Describe your injuries resulting from this accident or occurrence:

___________________________________________________________________

2. Do you claim permanent disability resulting from this injury? ( ) Yes ( ) No

If yes, describe the injuries believed to be permanent.

3. For each hospital, doctor, or other practitioner rendering treatment examination or diagnostic service state:

Name of hospital or doctor or other facility :

___________________________________________________________________

Address: ___________________________________________________________________

Dates if treatment or services: ___________________________________________________________________

Amount of charges to date: ___________________________________________________________________

Amount paid or payable by other sources such as insurance: ___________________________________________________________________

4. If you claim loss of wages or income as a result of the injury state: ___________________________________________________________________

Name of employer: Address of employer:

___________________________________________________________________

Your Occupation: Dates employed at this job:

___________________________________________________________________

Rate of Pay: Dates of absence from work:

___________________________________________________________________

Total of lost wages: If still out of work expected date of return: $___________________________________________________________________

Note: If your claimed loss of income arises form self-employment or other than wages, attach a calculation showing the basis of your calculation of lost income.

5. Set forth any and all other losses or damages claimed by you: ___________________________________________________________________

c. If you claim property damage: ___________________________________________________________________

1. Describe the property damaged:

___________________________________________________________________

2. The present time and location where item can be examined: ___________________________________________________________________

3. Date property was acquired: ___________________________________________________________________

4. Cost of the property: ___________________________________________________________________

5. Value of property at time of accident: ___________________________________________________________________

6. Description of damage:

___________________________________________________________________

7. Has the damage been repaired? If so by whom? ___________________________________________________________________

8. Attach each estimate of repair costs to this form. ___________________________________________________________________

9. Set forth in detail the loss claimed by you for property damage: ___________________________________________________________________

d. Set forth in detail all other items of loss or damages claimed by you and the method by which you made the calculation. ___________________________________________________________________

5. The amount of the claim: ___________________________________________________________________

6. Have you made a claim against anyone else for any of the losses claimed in this notice? ___________________________________________________________________

If yes set forth the names and addresses of all persons and insurance companies whom you've made claims against. ___________________________________________________________________

7. Are any of the losses or expenses claimed herein covered by any policy of insurance? ___________________________________________________________________

8. Have you received or agreed to receive any money from anyone for the damages claimed herein? If so set forth the details of this agreement. ___________________________________________________________________

9. The following items must be submitted with his notice: ___________________________________________________________________

(1) Copies of itemized bills for each medical expense and other losses and expenses claimed.

___________________________________________________________________

(2) Full copies of all appraisals and estimates of property damage claimed by you...

___________________________________________________________________

(3) Copies of all written reports of all expert witnesses and treating physicians..

___________________________________________________________________

(4) A letter from your employer verifying your lost wages. If self employed, a statement showing the calculation of your claimed lost income. ___________________________________________________________________

I hereby certify that the foregoing statements made by me are true, that the attached statements, bills, reports and documents are the only ones known to me to be in existence at this time. I am aware that if any statement made herein is willfully false or fraudulent, that I am subject to punishment provided by law.

Dated: ________________________________________

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