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1997-07-22
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294 lines
#400
@001 Enter the name of the AGENCY:
~Enter the name of the agency to whom the claim is being
~presented.
@002 Enter the street address of the AGENCY:
~Enter the street address of the agency.
@003 Enter the city, state zip code of the AGENCY:
~Enter the city, state and zip code of the agency's office
~receiving the claim.
#end control section
#400
CLAIM FOR DAMAGES OR INJURY
@001
@002
@003
GENERAL INFORMATION
1. Claimant--
(a) Full name: __________________________________________
(b) Address: ____________________________________________
City: _________________________ County: _________________
State: _________________ Zip Code: _____________________
(c) Age: _______ (d) Marital status: ___________________
2. If claimant is married, name and address of spouse:
_________________________________________________________
_________________________________________________________
AMOUNT OF CLAIM
3. Amount claimed for property damage: __________________
4. Amount claimed for personal injury: __________________
5. Total amount claimed: ________________________________
ACCIDENT RESULTING IN CLAIM
6. Place of accident (include town or city and state; if outside
city limits, indicate distance to nearest city or town):
_________________________________________________________
7. Date and time of accident: ___________________________
_________________________________________________________
(a) Day of week: ________________________________________
(B) Date: _______________________________________________
(C) Time: _______________________________________________
8. Description of accident
(a) Names and addresses of persons involved: ____________
_________________________________________________________
(b) Identification of property involved: ________________
_________________________________________________________
(c) Surrounding circumstances: __________________________
_________________________________________________________
(d) Cause of accident: __________________________________
_________________________________________________________
(e) Other pertinent facts: ______________________________
_________________________________________________________
9. Name and addresses of witnesses to accident: _________
_________________________________________________________
PROPERTY DAMAGE AND PERSONAL INJURY
10. Property damage
(a) Description of property damaged: ____________________
_________________________________________________________
(b) Present location: ___________________________________
(c) Name and address of owner, if other than claimant: __
_________________________________________________________
(d) Nature of damage: ___________________________________
(e) Extent of damage: ___________________________________
11. Personal injury
(a) Nature of injury: ____________________________________
__________________________________________________________
(b) Extent of injury: ____________________________________
__________________________________________________________
INSURANCE COVERAGE
12. Collision insurance
(a) Does claimant carry collision insurance? [If yes, answer (b)-
(f) below]
(b) Name and address of insurer: _________________________
_________________________________________________________
(c) Policy No.: _________________________________________
(d) Has claimant filed claim against insurer in this instance?
_________________________________________________________
(e) If claim has been filed, is coverage for full amount of loss?
_________________________________________________________
If not full coverage, amount deductible: ________________
_________________________________________________________
(f) If claim has been filed, action taken or proposed to be taken
by insurer with respect to claim:
_________________________________________________________
13. Public liability and property damage insurance
(a) Does claimant carry public liability and property damage
coverage?
_________ [If yes, answer (b) below]
(b) Name of insurer: ____________________________________
I declare under the penalty of perjury that the amount of this
claim covers only damages and injuries caused by the accident
described above. I agree to accept that amount in full
satisfaction and final settlement of this claim.
Dated: __________________________
_______________________________________________
Signature