Fillable Notice of Claim Instructions (State of New Jersey)

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Notice of Claim Instructions (State of New Jersey)

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Notice of Claim Instructions
If you wish to make a claim against the State of New Jersey, please read the
following information:
The State of New Jersey is protected from Tort actions by State Statute Title
59, and more specifically, Chapter 9, Paragraph 2e. Simply stated, Title 59:
9-2e means that, if you have insurance to cover "physical damage" to your
property, the money you are entitled to receive under such policy of insurance
shall be deducted from your claim against the State.
To expedite settlement of your claim, we ask that you settle your physical
damage with your physical damage insurance carrier.
You may submit a claim for your deductible by forwarding a copy of your
estimate and a copy of the declaration sheet showing the amount of your
physical damage deductible to the address listed below.
If you do not have "physical damage" coverage and wish to submit a claim,
please forward an estimate for the damage, a copy of the declaration sheet from
your insurance policy, and complete the enclosed Tort claim form.
Since all claims which are filed against the State of New Jersey must be filed
within 90 days of their occurrence, we suggest that your documentation be sent
via certified mail. Although this is not required, it will insure that you have
proof of receipt by this office.
Please allow a minimum of 90 days for a reply to your claim submittals.
Mail your response to:
Dept. of Treasury
Bureau of Risk Management
P.O. Box 620
Trenton, NJ 08625
Attn.: Tort Claims Unit
INITIAL NOTICE OF CLAIM FOR DAMAGES AGAINST THE STATE OF NEW JERSEY
FORWARD TO: TORT AND CONTRACT UNIT
DEPARTMENT OF THE TREASURY, BUREAU OF RISK MGMT.
PO BOX 620
TRENTON, NEW JERSEY 08625
PHONE: (609) 292-4347
FORM MUST BE FILED WITHIN 90 DAYS OF THE ACCIDENT OR YOU MAY FORFEIT YOUR RIGHT
1. CLAIMANT:
LAST NAME
DATE OF BIRTH
MAILING ADDRESS
NAME
2. IF NOTICES AND CORRESPONDENCE IN CONNECTION WITH THIS CLAIM ARE TO BE SENT TO A PERSON OTHER THAN
CLAIMANT, COMPLETE ITEM #2.
EXPLAIN RELATIONSHIP
3. CIRCUMSTANCES REGARDING THE OCCURRENCE OR ACCIDENT :
DATE TIME
MAILING ADDRESS IF OTHER THAN ADDRESS
4. DESCRIBE THE ACCIDENT OR OCCURENCE.
MIDDLE
FIRST
SOCIAL SECURITY NUMBER
TELEPHONE
ORATTORNEY AT LAWRELATIONSHIP TO CLAIMANT:
EXACT LOCATION OF THE OCCURRENCE
ADDRESS
Telephone
ADDRESS
6. STATE THE NAMES AND ADDRESSES OF EACH STATE AGENCY OR AGENCIES AND EACH STATE EMPLOYEE WHOM YOU CLAIM CAUSED YOUR
DAMAGES OR INJURIES.
7. STATE THE NAME AND ADDRESS OFALLOTHER PERSONS, COMPANIES OR GOVERNMENTAL AGENCIES WHICH YOU CLAIM ARE RESPONSIBLE FOR
YOUR INJURIES OR DAMAGES.
8. BRIEFLY DESCRIBE THE INJURIES, DAMAGES AND LOSSES INCURRED BY YOU.
5. STATE THE NAME AND ADDRESS OF ALL WITNESSES TO THE ABOVE ACCIDENT OR OCCURRENCE.
9. THE AMOUNT OF THE CLAIM.
GIVE THE BASIS FOR THE CALCULATION OF THE ABOVE DAMAGES:
I HEREBY CERTIFY THAT THE FOREGOING STATEMENTS MADE BY ME ARE TRUE. I AM AWARE THAT IF ANY STATEMENT MADE HEREIN IS
WILLFULLY FALSE OR FRAUDULENT, THAT I AM SUBJECT TO PUNISHMENT PROVIDED BY LAW.
DATE CLAIMANT OR PERSON FILING ON BEHALF OF CLAIMANT
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Completed 13 October 2020

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