Tort Claim Account Form

TORT CLAIM ACCOUNT FORM

This Tort Claim Account Form is submitted by Claimant Name: and is filed against Respondent Name: for the purpose of asserting a tort claim arising from the events described below.

RECITALS

WHEREAS, Claimant asserts that on the date and at the location stated in Section 2 below, Claimant suffered loss, injury, or damage as a result of the acts or omissions of the Respondent or its employees, agents, contractors or representatives; and

WHEREAS, Claimant submits this Tort Claim Account Form to provide account information, factual particulars, and an itemization of losses to enable investigation and administrative disposition of the asserted claim; and

WHEREAS, Respondent requires a written claim containing sufficient information to investigate and evaluate potential liability and damages;

NOW THEREFORE, the Parties set forth the following account of claim information, certifications and authorizations in support of the claim.

1. CLAIMANT INFORMATION

2. INCIDENT DETAILS

Date of Incident:   Time of Incident:

3. NATURE OF CLAIM AND DAMAGES

Nature of Claim (check all that apply): Property Damage Personal Injury Wrongful Death Other

4. INSURANCE / OTHER COVERAGE

Has a prior claim been filed regarding this incident? Yes No

5. SUPPORTING DOCUMENTATION

Please indicate which documents are attached (check all that apply):

6. CERTIFICATION, AUTHORIZATION AND ACKNOWLEDGMENTS

By signing below, Claimant certifies under penalty of perjury that the information contained in this Tort Claim Account Form and any attachments is true and correct to the best of Claimant's knowledge. Claimant further certifies that the amounts claimed are accurate as of the date of this submission.

Claimant hereby authorizes any physician, hospital, or other health care provider to release medical records and billing information pertaining to treatment relating to the incident described herein to Respondent or its authorized representative for the purpose of verifying the claim. Claimant acknowledges that such authorization is limited to records and bills reasonably related to the asserted claim.

I certify that the statements made in this form are true and that I am the person entitled to make this claim or am authorized to act on behalf of the person injured or the estate thereof.

7. NOTICES, REMEDIES AND ADMINISTRATIVE TERMS

Notices under this form shall be in writing and delivered to the addresses provided by the Parties in Section 1 or by separate written notice. Receipt of notice is effective upon personal delivery or three business days after deposit into the mail with first-class postage prepaid.

This form provides information required for the initial administrative claim account. Submission of this form does not constitute an admission of liability by Respondent nor a waiver of any defenses. Respondent retains all statutory and common-law defenses in responding to, investigating and adjudicating the claim.

8. GENERAL PROVISIONS

Governing Law: This claim account form and any administrative proceedings arising from it shall be governed by the laws of the jurisdiction in which Respondent is located, without regard to its conflict of laws rules.

Entire Agreement: This form, together with attachments submitted herewith, constitutes the entire written statement of the claim account; no oral statements or other writings will modify the information provided herein except by written amendment executed by the Parties.

Severability: If any provision of this form is held invalid or unenforceable, the remaining provisions remain in full force and effect.

Amendments and Waiver: Any amendment to this claim account must be in writing and signed by the party making the amendment. Failure to enforce any provision shall not constitute a waiver of that provision.

Counterparts: This form may be executed in counterparts, each of which constitutes an original and all of which together constitute one instrument.

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