THIS CLAIM FORM MUST BE FILED WITHIN NINETY DAYS OF

THIS CLAIM FORM MUST BE FILED WITHIN NINETY DAYS OF
ACCIDENT/OCCURRENCE OR YOU MAY FORFEIT YOUR RIGHTS PURSUANT TO
N.J.S.A. 59:1 ET SEQ.
1) CLAIMAINT INFORMATION
DATE OF ACCIDENT
$
AMOUNT OF CLAIM
LAST NAME, FIRST NAME, MIDDLE
DATE OF BIRTH
STREET ADDRESS
MAILING ADDRESS
CITY, STATE ZIP CODE
SOCIAL SECURITY NUMBER
MARITAL STATUS
NUMBER OF DEPENDENTS
PRIMARY PHONE
WORK PHONE
IF NOTICE AND CORRESPONDENCE IN CONNECTION WITH THIS CLAIM ARE TO BE SENT TO A PERSON OTHER
THAN THE CLAIMANT, COMPLETE ITEM No. 2.
2) CLAIMAINT INFORMATION
NAME
MAILING ADDRESS
CITY, STATE, ZIP CODE
RELATIONSHIP TO CLAIMANT ATTORNEY-AT-LAW
OR
RELATIONSHIP
3) THE OCCURRENCE OR ACCIDENT WHICH HAS GIVEN RISE TO THIS CLAIM:
3A. DATE
TIME
B. DESCRIBE THE LOCATION OR PLACE OR THE OCCURRENCE:
MUNICIPALITY
EXACT LOCATION OF THE OCCURENCE
C. DESCRIBE HOW THE ACCIDENT OR OCCURRENCE HAPPENED. IF A DIAGRAM WILL ASSIT
YOUR EXPLANATION, PLEASE ATTACH HERETO.
D. STATE THE NAMES OF THE PUBLIC EMPLOYEES AND OR PUBLIC AGENCIES WHOM YOU CLAIM
WERE AT FAULT, INCLUDING ANY INFORMATION THAT WILL ASSIST IDENTIFYING AND LOCATING
THEM.
E. STATE THE NEGLIGENCE OR WRONGFUL ACTS OF THE PUBLIC AGENCY OR ITS EMPLOYEES
WHICH ALLEGEDLY CAUSED YOUR DAMAGES.
F. STATE THE NAME AND ADDRESS OF ALL WITNESSES TO THE ACCIDENT OR OCCURENCE.
G. STATE THE NAME AND ADDRESS OF ALL POLICE OFFICERS AND POLICE DEPARTMENTS WHO
INVESTIGATED THE ACCIDENT.
H. DID LOSS OR INJURY OCCUR DURING THE COURSE AND SCOPE OF YOUR
EMPLOYMENT?_________
4(A) CLAIM FOR DAMAGES ( CHECK APPROPRIATE BLOCK)
(
) PROPERTY DAMAGES
(
) PERSONAL INJURY
( ) OTHER EXPLAIN IN DETAIL
(B) IF YOU CLAIM PERSONAL INJURY:
(1) DESCRIBE YOUR INJURIES 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 TREATMENT,EXAMINATION, OR
DIAGNOSTIC SERVICE, STATE:
I. NAME OF HOSPITAL
II.ADDRESS
III DATES OF TREATMENT
IV.AMOUNT
DOCTOR OR OTHER
OR
SERVICE
OF CHARGES
TREATMENT FACILITY
TO DATE
(4) ARE YOU COVERED BY ANY HEALTH INSURANCE POLICY? IF SO, PLEASE ADVISE NAME AND ADDRESS OF
CARRIER, NAMED INSURED AND POLICY NUMBER.
LIST BILLS SUBMITTED TO CARRIER.
(5) IF YOU CLAIM LOSS OF WAGES OR INCOME AS A RESULT OF THE INJURY, STATE:
NAME OF EMPLOYER
ADDRESS OF EMPLOYER
YOUR OCCUPATION
DATE YOU BECAME EMPLOYED AT THIS JOB
RATE OF PAY
DATES OF ABSENCE FROM WORK
TOTAL LOST WAGES TO DATE
IF STILL OUT OF WORK, EXPECTED DATE TO RETURN
IF INJURY IS ASSOCIATED WITH AN AUTO ACCIDENT, PLEASE PROVIDE THE NAME OF THE AUTO INSURANCE
CARRIER AND POLICY NUMBER.
NOTE: IF YOUR CLAIMED LOSS OF INCOME ARISES FROM SELF EMPLOYMENT OR OTHER THAN WAGES, ATTACH
A CALCULATION SHOWING THE BASIS OF YOUR CALCULATION OF LOST INCOME.
(6) SET FORTH ANY AND ALL LOSSES OR DAMAGES CLAIMED BY YOU.
A.
IF YOU ARE CLAIMING PROPERTY DAMAGE:
(1) DESCRIBE THE PROPERTY DAMAGED.
(2) PRESENT LOCATION AND TIME WHEN THE PROPERTY MAY BE INSPECTED.
(3) DATE PROPERTY ACQUIRED
(4) COST OF PROPERTY $
(5) VALUE OF PROPERTY AT TIME OF
ACCIDENT
(6) DESCRIPTION OF DAMAGE.
(7) HAS THE DAMAGE BEEN REPAIRED?
IF SO, BY WHOM, WHEN AND
COST OF REPAIRS?
(8) ATTACH EACH ESTIMATE OF REPAIR COSTS TO THIS FORM.
(9) SET FORTH IN DETAIL THE LOSS CLAIMED BY YOU FOR PROPERTY DAMAGE.
A.
SET FORTH IN DETAIL ALL OTHER ITEMS OF LOSS OR DAMAGES CLAIMED BY YOU AND THE
METHOD BY WHICH YOU MADE THE CALCULATION.
(10) STATE THE TOATAL AMOUNT OF DAMAGES
(PERSONAL,PROPERTY AND OTHER) YOU ARE CLAIMING.
(11) HAVE YOU MADE A CLAIM AGAINST ANYONE ELSE
FOR ANY OF THE LOSSES OR EXPENSES CLAIMED IN THIS
NOTICE?
IF YES, SET FORTH THE NAMES AND ADDRESSES OF ALL PERSONS AND INSURANCES COMPANIES AGAINST WHOM YOU
HAVE MADE SUCH CLAIMS.
(12) ARE ANY OF THE LOSSES OR EXPENSES CLAIMED HEREIN COVERED BY ANY POLICY
OF INSURANCE? _______________________________________________________________________
FOR EACH SUCH POLICY, STATE THE NAME AND ADDRESS OF THE INSURANCE COMPANY, POLICY NUMBER AND
BENEFITS PAID OR PAYABLE..
(13) HAVE YOU RECEIVED OR AGREED TO RECEIVE ANY MONEY FROM ANYONE FOR THE DAMAGES CLAIMED
HEREIN _______________IF SO, SET FORTH THE DETAILS OF SUCH AGREEMENT.
THE FOLLOWING ITEMS MUST BE SUBMITTED WITH THIS NOTICE:
(1) COPIES OF ITEMIZED BILLS FOR EACH MEDICAL EXPENSES 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 LOST WAGES. IF SELF EMPLOYED, A
STATEMENT SHOWING CALCULATION OF YOUR CLAIMED LOST INCOME.
I HERE CERTIFY THAT THE FOREGOING STATEMENT MADE BY ME ARE TRUE. THAT THE
ATTACHED STATEMENTS, BILLS, REPORTS AND DOCUMENTS ARE THE ONLY ONE KNOWN TO
ME 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.
CLAIMANT OR PERSON FILING ON BEHALF OF CLAIMANT
DATE:_____________________
TO WHOM IT MAY CONCERN:
I HEREBY AUTHORIZE ANY AND ALL DOCTORS, HOSPITALS, OR OTHER MEDICAL SERVICES
FACILITIES TO RELEASE TO THE CITY OF UNION CITY, OR THEIR REPRESENTATIVE ANY AND
ALL RECORDS, REPORTS AND OTHER INFORMATION CONCERNING THE TREATMENT OF THE
CLAIMANT NAMED HEREIN.
I ALSO, HEREBY AUTHORIZE MY EMPLOYER TO RELEASE ALL WAGES, SALARY AND
RELATED COMPENSATION INFORMATION.
____________________________________________
SIGNATURE
DATE:_______________________________________
(THIS MUST BE SIGNED BY THE CLAIMANT OR THE PARENTS OF CLAIMANTS WHO ARE MINORS)
COMPLETED FORM MUST BE FORWARDED TO:
OFFICE OF THE MUNICIPAL CLERK
CITY OF UNION CITY
3715 PALISADE AVE
Union City, New Jersey 07087