Establishing secure connection…Loading editor…Preparing document…

Tort Claim Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

NOTICE OF TORT CLAIM FOR PROPERTY DAMAGE AND/OR PERSONAL INJURY

State Form 54668 (3-11)

Special Investigations Division

INSTRUCTIONS:

Anyone who has a claim for personal injury or property damage against the State of Indiana must either use this form to file a claim or make the claim in writing as prescribed in Indiana Code 34-13-3. Immunities are listed on the back of this form.

1. If applicable, include copies of accident/incident report, vehicle registration, paid receipts for repair or two (2) estimates for repair, medical reports, photographs and any additional documentation in reference to this matter.

2. Each person who had a loss should file a separate form.

3. Sign and date this form.

4. State statute requires the claim be delivered in person or be sent via Certified or Registered mail to the address in the upper right corner above.

5. Do not delay making your claim. Indiana law gives you two hundred seventy (270) days after the loss to make a claim and it must comply with Indiana Code 34-13-3.

6. Keep a copy of your claim form, receipts, bills and certified/registered mail receipt.

7. If your claim is properly filed, the Office of the Attorney General will investigate it and notify you in writing within ninety (90) days of each receipt if your claim is approved. A claim is denied if not approved within ninety (90) days.

8. The filing of this claim is part of a legal process. If you have any questions about the right way to file a claim, please contact an attorney of your choice. The state's attorneys are not authorized by law to assist you with filing this claim. For your information a list of actions, or conditions, resulting in non-liability pursuant to Indiana Code 34-13-3 as shown on the back of this form.

OFFICE OF ATTORNEY GENERAL

ATTN: Tort Claim Investigations

Government Center South, 5th floor

302 W. Washington Street

Indianapolis, IN 46204

Telephone: (317) 232-6350

CLAIMANT INFORMATION

Name

Home Telephone

Work Telephone

Cellular Telephone

Address at Time of Loss (number and street, city, state, and ZIP code)

Email Address

Current Address (if different from above)

Driver License Number

Issuing State

Vehicle License Plate Number (if involved)

Issuing State

LOSS INFORMATION

Date of Loss (m/d/yy)

Time of Loss

Dollar Amount of Loss

State Agency Involved

State Vehicle Commission (if known)

Exact Location of Loss (include town, street & nearest crossroad)

Loss County

Names/Addresses of All Persons Involved (if known)

Alleged Negligence

Explanation of what happened (use additional sheets if necessary)

Please read: I swear and affirm under the penalties for perjury that the foregoing information is true and correct to the best of my knowledge and belief.

Claimant's Signature

Date (m/d/yy)

Immunity of governmental entity or employee

A governmental entity or an employee acting within the scope of the employee's employment is not liable if a loss results from the following:

(1) The natural condition of unimproved property.

(2) The condition of a reservoir, dam, canal, conduit, drain, or similar structure when used by a person for a purpose that is not foreseeable.

(3) The temporary condition of a public thoroughfare or extreme sport area that results from weather.

(4) The condition of an unpaved road, trail, or footpath, the purpose of which is to provide access to a recreational or scenic area.

(5) The design, construction, control, operation, or normal condition of an extreme sport area, if all entrances to the extreme sport area are marked with:

(A) a set of rules governing the use of the extreme sport area;

(B) a warning concerning the hazards and dangers associated with the use of the extreme sport area; and

(C) a statement that the extreme sport area may be used only by persons operating extreme sport equipment.

This subdivision shall not be construed to relieve a governmental entity from liability for the continuing duty to maintain extreme sports areas in a reasonably safe condition.

(6) The initiation of a judicial or an administrative proceeding.

(7) The performance of a discretionary function; however, the provision of medical or optical care as provided in IC 34-6-2-38 shall be considered as a ministerial act.

(8) The adoption and enforcement of or failure to adopt or enforce a law (including rules and regulations), unless the act of enforcement constitutes false arrest or false imprisonment.

(9) An act or omission performed in good faith and without malice under the apparent authority of a statute which is invalid if the employee would not have been liable had the statute been valid.

(10) The act or omission of anyone other than the governmental entity or the governmental entity's employee.

(11) The issuance, denial, suspension, or revocation of, or failure or refusal to issue, deny, suspend, or revoke any permit, license, certificate, approval, order, or similar authorization, where the authority is discretionary under the law.

(12) Failure to make an inspection, or making an inadequate or negligent inspection, of any property, other than the property of a governmental entity, to determine whether the property complied with or violates any law or contains a hazard to health or safety.

(13) Entry upon any property where the entry is expressly or impliedly authorized by law.

(14) Misrepresentation if unintentional.

(15) Theft by another person of money in the employee's official custody, unless the loss was sustained because of the employee's own negligent or wrongful act or omission.

(16) Injury to the property of a person under the jurisdiction and control of the department of correction if the person has not exhausted the administrative remedies and procedures provided by section 7 of this chapter.

(17) Injury to the person or property of a person under supervision of a governmental entity and who is:

(A) on probation; or

(B) assigned to an alcohol and drug services program under IC 12-23, a minimum security release program under IC 11-10-8, a pretrial conditional release program under IC 35-33-8, or a community corrections program under IC 11-12-1.

(18) Design of a highway (as defined in IC 9-13-2-73), toll road project (as defined in IC 8-15.5-1-2), toll road project (as defined in IC 8-15.5-1-3), or project (as defined in IC 8-15.5-1-2), toll road project, tollway, or project, designed or substantially redesigned; except that this subdivision shall not be construed to relieve a responsible governmental entity from the continuing duty to provide and maintain public highways in a reasonably safe condition.

(19) Development, adoption, implementation, operation, maintenance, or use of an enhanced emergency communication system.

(20) Injury to a student or a student's property by an employee of a school corporation if the employee is acting reasonably under a discipline policy adopted under IC 20-33-8-12.

(21) An act or omission performed in good faith under the apparent authority of a court order described in IC 35-46-1-15.1 that is invalid, including an arrest or imprisonment related to enforcement of the court order, if the governmental entity or employee would not have been liable had the court order been valid.

(22) An act taken to investigate or remediate hazardous substances, petroleum, or other pollutants associated with a brownfield (as defined in IC 13-11-2-193) unless:

(A) the loss is a result of reckless conduct; or

(B) the governmental entity was responsible for the initial placement of the hazardous substances, petroleum, or other pollutants on the brownfield.

(23) the operation of an off-road vehicle (as defined in IC 14-8-2-185) by a nongovernmental employee, or by a governmental employee not acting within the scope of the employment of the employee, on a public highway in a county road system outside the corporate limits of a city or town, unless the loss is the result of an act or omission amounting to:

(A) gross negligence;

(B) willful or wanton misconduct; or

(C) intentional misconduct.

This subdivision shall not be construed to relieve a governmental entity from liability for the continuing duty to maintain highways in a reasonably safe condition for the operation of motor vehicles licensed by the bureau of motor vehicles for operation on public highways.

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What a Tort Claim Form Is and when it applies

A Tort Claim Form is a formal written notice submitted to a public entity or private party describing an alleged tort—typically personal injury, property damage, or negligence—and the damages sought. Many jurisdictions require submission of a timely claim or notice as a prerequisite to filing suit against a government body. The form documents claimant identity, incident details, witnesses, injury or damage descriptions, and a signed certification. Proper completion preserves procedural rights, starts the administrative review, and creates a record for insurance and litigation purposes.

Why completing a clear Tort Claim Form matters

Filing a complete Tort Claim Form protects legal rights, notifies the responsible agency, and triggers administrative review. It helps establish timelines, documents damages and witnesses, and can shorten or avoid later litigation by enabling early settlement or agency action.

Why completing a clear Tort Claim Form matters

Who interacts with a Tort Claim Form

Several roles prepare, submit, or respond to Tort Claim Forms; each has specific responsibilities and recordkeeping needs.

  • Individual claimants and injured parties who file the initial notice with a government office or private insurer.
  • Attorneys and authorized representatives who draft narrative descriptions, calculate damages, and handle service and deadlines.
  • Risk managers, claims examiners, and municipal legal staff who review, investigate, and accept or deny claims.

Knowing your role clarifies which sections you complete, what supporting documents to attach, and who must sign or certify the submission.

Step-by-step: completing the Tort Claim Form

Follow these sequential steps to prepare, verify, and submit a clear Tort Claim Form and supporting evidence.

  • 01
    Gather evidence: Collect photos, police reports, medical bills, and witness contact information before drafting the form.
  • 02
    Complete the form: Fill every required field in the specified format and attach supporting documents as instructed.
  • 03
    Authenticate signatures: Sign in ink or use an accepted electronic signature method; include agent authorization if applicable.
  • 04
    Submit and retain: File per agency instructions, note the receipt or tracking number, and keep certified copies for records.

Essential sections to include on a professional Tort Claim Form

A complete Tort Claim Form groups claimant data, incident facts, damages, witnesses, responsible entity identification, and certification in a standard layout for efficient review.

Claimant Details

Full legal name, contact information, mailing address, relationship to damaged property, and any authorized representative information for service and follow-up.

Incident Facts

Date, time, and precise location of the event; short factual narrative describing what happened without legal conclusions.

Damages and Losses

Itemized property damage, medical treatment summary, lost wages, and a stated monetary claim or estimate of damages.

Witness Information

Names, contact details, and short statements or notes about witness observations to assist agency investigation and potential discovery.

Responsible Entity

Identify the government agency, department, or private party alleged to be responsible and include contact or department codes if known.

Certification & Signature

Signed declaration that information is true to the claimant's knowledge, dated signature, and any required notarization or agent authorization.

Required data elements at a glance

Claimant Name: Full legal name
Date of Birth: DOB for identity checks
Contact Address: Street, city, state, ZIP
Incident Date: MM/DD/YYYY format
Claim Amount: Specific dollar value
Signatures: Signed and dated

Submission flow: from form to agency response

Understand the typical flow so you can document each handoff and track response deadlines.

  • Preparation: Assemble facts, estimate damages, and complete required fields.
  • Authentication: Sign physically or with an accepted electronic method; notarize if required.
  • Filing: Deliver to the correct agency office by accepted channel and obtain proof of receipt.
  • Agency Review: Agency investigates, requests additional info, and issues acceptance, settlement offer, or denial.

Configure an online Tort Claim Form workflow

Set up fields, authentication, and routing so online submissions meet statutory and agency requirements.

Field Configuration
Authentication Email with optional SMS code
Signature Type Electronic signature or notarized PDF
Attachments Support PDFs, photos, and reports
Routing Single recipient or sequential review

Digital submission and file format considerations

When using an online platform, confirm accepted file formats, authentication methods, and integrations with agency systems.

  • File formats: PDF, DOCX preferred
  • Integrations: Supports cloud storage and CRM links
  • Security: TLS and encrypted at rest

Ensure the platform preserves an audit trail (timestamps, IP, event log) and stores a copy in a tamper-evident format for later proof.

Consequences of an incorrect or late Tort Claim Form

Missed Deadline: Loss of right to sue in many jurisdictions
Incomplete Details: Investigation delays and possible denial
Unsigned Submission: Form may be rejected as invalid
Incorrect Defendant: Service defects and dismissal risk
Unsupported Damages: Reduced settlement or denial
Data Inconsistency: Compromised evidentiary value

Common mistakes to avoid

  • Failing to attach essential evidence such as police or medical reports delays review.
  • Providing different names or inconsistent dates between documents causes identity verification issues.
  • Estimating damages without supporting invoices or bills weakens negotiation position and may limit recovery.
  • Using vague descriptions instead of factual, time-stamped observations impedes agency investigation.

Who may lawfully sign or submit the form

Claimant — Individual

The injured or damaged party should sign to verify factual statements; if a minor or incapacitated, a guardian or authorized representative must sign and attach proof of authority.

Authorized Representative — Attorney

An attorney or agent with written authorization may sign on the claimant’s behalf; include a power of attorney or engagement letter to show authority.

Typical deadlines and agency processing expectations

Notice and processing times vary; check the applicable statute or agency instructions because missing a deadline may forfeit claim rights.

Statutory Notice:

Varies widely by state; many require notice within months of the incident

Agency Response:

Agencies commonly reply within 30–90 days after receipt

Time to Sue:

If denied, the time to file suit is set by statute and can be short

Document Requests:

Agencies may request additional records within a defined review window

Evidence Preservation:

Preserve photos, medical records, and receipts immediately after the incident

eSignature platform comparison for submitting Tort Claim Forms

Compare common eSignature plan attributes to assess compatibility with filing needs, HIPAA/record retention, and bulk operations.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day trial Varies Varies Varies Varies
Bulk Send Yes (Premium) Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 env/user/yr Varies Varies Varies

Practical examples of Tort Claim Form use

Real organizations use digital workflows to accelerate claim submission and preserve evidence — here are representative examples.

Optica Ventures LLC

Optica streamlined claimant intake using an online form for incident capture.

  • The interface is simple and easy-to-use.
  • Brian Fitzgibbons, COO, reported the system is easy for their team and customers while improving record consistency and speed to review.

Martin Properties

A property manager digitized tenant damage claims to centralize evidence.

  • Mobile signing and attachments sped reporting.
  • Tim Martin, Founder, explained that online processing enabled compliant, efficient collection of signed statements and photos without in-person meetings.

Practical tips for accurate and efficient completion

Follow these practices to reduce processing time, avoid rejections, and preserve rights.

Meet statutory notice periods
Confirm the applicable notice deadline before filing and use return receipt or tracked electronic delivery to establish filing date and compliance.
Attach supporting evidence
Include police reports, estimates, medical records, and witness contact details to substantiate liability and damages at first submission.
Use consistent names and dates
Ensure claimant name, dates, and locations match all supporting documents and identification to avoid identity verification issues.
Preserve an audit trail
Retain copies of the submitted form, signature audit records, and delivery confirmations in a secure, tamper-evident format.

Common questions about Tort Claim Forms

Answers to frequent questions about form validity, signing, submission, and next steps when a claim is denied.


Need help? Contact support

Explore Templates

Employer Employee Agreement First Set Interrogatories Indigency Form Florida Verification Letter HIPAA Compliance Agreement
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.