Fillable CLAIM AGAINST THE STATE OF NEVADA (State of Nevada, Department of Information Technology)

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CLAIM AGAINST THE STATE OF NEVADA (State of Nevada, Department of Information Technology)

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CLAIM AGAINST THE STATE OF NEVADA
TO:
Claims Manager
Office of the Attorney General
DMV Legal/Tort Claims
555 Wright Way
Carson City, NV 89711
(775) 684-1252 or (775) 684-1263
The following information is necessary to fairly evaluate your claim. Please provide complete information. If you
need more space, attach a separate sheet of paper. Additional evidence, such as photographs, police reports, etc.,
should be attached if available. However, such additional evidence will not be returned. Keep copies for your
records. PLEASE PRINT LEGIBLY OR TYPE. You must sign the claim form.
YOU ARE NO
T RE
QUIRED TO
MAKE
A CLAIM
P
RIOR TO
FILING
A LAWSUIT.
THE
MAKING
OF A CLAIM WILL NOT STOP THE RUNNING OF THE APPLICABLE STATUTE OF LIMITATIONS
•
You are the claimant if you are making this claim for yourself.
•
Your Client is the claimant if you are an attorney making a claim on behalf of a client.
•
Your Company is the claimant if you are making a claim on behalf of a business.
•
The Insurance Company is the claimant if you represent an insurance company.
1. CLAIMANT’S NAME __________________________________________________________________________________________
ADDRESS ____________________________________________________________________________________________________
______________________________________________________________________________________________________________
DATE OF BIRTH______________________ DAYTIME TELEPHONE NUMBER ( )____________________________
If you prefer to receive correspondence via EMAIL instead of U.S. Mail, please provide your email address:
_______________________________________________________________________________________________________________
2.
IF CLAIMANT IS A BUSINESS: Name of Employee involved in incident ________________________________________
Company Contact Person _______________________________________ Your
Reference ________________________________
3.
IF CLAIMANT IS AN INSURANCE COMPANY: Name of your “INSURED” _____________________________________
Claim Representative ______________________________________ Your
Claim No. ____________________________________
4. IF YOU ARE REPRESENTED BY AN ATTORNEY: We will only communicate with you through your attorney.
It is not necessary to retain an attorney to file a claim; however, if you have an attorney for this claim, please provide
the following information:
Attorney’s Name ___________________________
_
_
________________________________________________________________
Firm’s Name_________________________________________________________________________________________________
Address ______________________________________________________________________________________________________
______________________________________________________________________________________________________________
Phone Number: ( ) __________________________________ File Reference _____________________________________
5.
DATE AND TIME when the incident
occurred: __________________________________________________________________
6. Exact LOCATION where the incident occurred: _
_
_______________________________________________________________
7.
IF THIS IS AN AUTOMOBILE
ACCIDENT, please supply the following information:
YOUR VEHICLE
Year
__________ Make _
______________________
_ Model ________
__________________ License Number _______________
STATE VEHICLE
Year __________ Make ________________________ Model __________________________ License Number _______________
Received By AG’s Office: For AG’s Office Use Only:
Claim # ____
________ Dir. _________________
X-Ref ______________
Emp. ________________
DOL _______________ State Veh Lic ____
_____
B/A _______________ $ _
___________________
Agency _____________ Adj __________________
____________________ due __________________
Page 1 of 2
TC-1 (revised 7/19)
8. State the full names, addresses and phone numbers of all witnesses:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
9.
A CLAIM FOR $________________ is hereby made against the STATE OF NEVADA, based upon the following facts:
10.
Describe how damage or injury occurred and what the STATE OF NEVADA or its employees did to cause your
damage or injury. Give full details:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
A) State of NV Employee’s Name __________________________ B) State of NV Agency ____________________________
11.
Explain and support the amount of damages you have claimed. Please provide a MINIMUM OF 2 REPAIR
ESTIMATES for property damage. Also include any rental bills, receipts, medical reports, itemized statements, etc.
12.
If this claim i
s for personal
injury
and/or
payment
of
medical
expenses y
ou must answer
this question:
Are
you
covered under any type of Medicare Program. NO
YES
if yes: Pursuant to Federal Medicare rules, if
liability is accepted by the State of NV, you will be required, at a later date,
to provide your Medicare Health
Insurance Claim Number (HICN).
I, ________________________________, do hereby attest under penalty of perjury that I am the claimant named
above,
that I have read the foregoing claim and know the contents thereof, that the same is true of my own knowledge,
except those matters stated upon information and belief, and as to those matters, I believe them to be true, and
that THIS IS MY ENTIRE CLAIM AGAINST THE STATE OF NEVADA.
IF MY CLAIM IS PAID BY THE STATE OF NEVADA, I FULLY UNDERSTAND THAT I WILL HAVE TO SIGN A
RELEASE OF ALL CLAIMS IN THE PRESENCE OF A NOTARY PUBLIC FOR THE DETERMINED AMOUNT
BEFORE ANY PAYMENT WILL BE OFFERED TO ME. THIS RELEASE WILL BECOME EFFECTIVE ONLY
UPON ACTUAL PAYMENT OF THE CLAIM BY THE STATE OF NEVADA.
________________________________________________
Signature of Claimant (or Company Representative)
____________________________
Date
NOTICE: 197.160 of Nevada Revised Statutes provides that every person who knowingly presents a false claim is guilty of
a gross misdemeanor, and is subject to criminal penalties of imprisonment of up to one year, and a fine of up to $2,000.
Incomplete or unsigned claim forms will not be accepted and will be returned.
Claims may be submitted as follows:
Fax: 775-684-4601
Mail:
Claims Manager DMV
Legal/Tort Claims
555 Wright Way
Carson City, NV 89711
Page 2 of 2
TC-1 (revised 7/19)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Email: agclaims@ag.nv.gov
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CLAIM AGAINST THE STATE OF NEVADA (State of Nevada, Department of Information Technology)

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Completed 20 December 2020

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