Fillable Notice of Claim Instructions (The State of New Jersey)

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Notice of Claim Instructions (The 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
ZIP CODE
STREET ADDRESS
STATECITY
ZIP CODESTATECITY
MAILING ADDRESSNAME
IF NOTICES AND CORRESPONDENCE IN CONNECTION WITH THIS CLAIM ARE TO BE SENT TO A PERSON OTHER THAN
CLAIMANT, COMPLETE ITEM #2.
2.
EXPLAIN RELATIONSHIP
MUNICIPALITY
THE OCCURRENCE OR ACCIDENT WHICH GAVE RISE TO THIS CLAIM:
DATE TIME
MAILING ADDRESS IF OTHER THAN STREET ADDRESS
3a.
b. DESCRIBE THE LOCATION OR PLACE OF THE ACCIDENT OR OCCURENCE.
EXACT LOCATION OF THE OCCURRENCE
MIDDLEFIRST
SOCIAL SECURITY NUMBER
ORATTORNEY AT LAWRELATIONSHIP TO CLAIMANT:
STATE THE NAME AND ADDRESS OF THE STATE AGENCY OR AGENCIES THAT YOU CLAIM CAUSED YOUR DAMAGE.d.
STATE THE NAMES OF STATE EMPLOYEES WHOM YOU CLAIM WERE AT FAULT, INCLUDING ANY INFORMATION THAT WILL
ASSIST IN INDENTIFYING AND LOCATING THEM.
STATE THE NEGLIGENCE OR WRONGFUL ACTS OF THE STATE AGENCY AND STATE EMPLOYEES WHICH CAUSED YOUR
DAMAGES.
e.
STATE THE NAME AND ADDRESS OF ALL WITNESSES TO THE ACCIDENT OR OCCURRENCE.f.
STATE THE NAMES OF ALL POLICE OFFICERS AND POLICE DEPARTMENTS WHO INVESTIGATED THIS ACCIDENT.g.
4a. CLAIM FOR DAMAGES (CHECK APPROPRIATE BLOCK):
PERSONAL INJURY PROPERTY DAMAGE
OTHER - EXPLAIN IN DETAIL
DESCRIBE HOW THE ACCIDENT OR OCCURENCE HAPPENED: IF A DIAGRAM WILL ASSIST YOUR EXPLANATION, PLEASE USE
THE REVERSE SIDE OF THIS FORM.
c.
(2) DO YOU CLAIM PERMANENT DISABILITY RESULTING FROM THIS INJURY:
YES NO
IF YES, DESCRIBE THE INJURIES BELIEVED TO BE PERMANENT.
(3) FOR EACH HOSPITAL, DOCTOR OR OTHER PRACTITIONER RENDERING TREATMENT, EXAMINATION OR DIAGNOSTIC
SERVICES, STATE:
NAME OF HOSPITAL,
DOCTOR OR OTHER
FACILITY
ADDRESS
DATES OF
TREATMENT OR
SERVICE
AMOUNT OF
CHARGE TO
DATE
AMT. PAID OR PAYABLE BY
OTHER SOURCE SUCH AS
INSURANCE
(4) IF YOU CLAIM LOSS OF WAGE OR INCOME AS A RESULT OF THE INJURY STATE:
NAME OF EMPLOYER ADDRESS OF EMPLOYER
RATE OF PAY
TOTAL LOSS WAGES TO DATE
YOUR OCCUPATION DATE YOU BECAME EMPLOYED
DATE OF ABSENCE FROM WORK
IF STILL OUT, EXPECTED DATE OF RETURN
NOTE: IF YOUR CLAIMED LOSS OF INCOME ARISES FROM SELF-EMPLOYMENT OR OTHER THAN WAGE, ATTACH A
CALCULATION SHOWING THE BASIS OF YOUR CALCULATION OF LOST INCOME.
(1) DESCRIBE YOUR INJURIES RESULTING FROM THIS ACCIDENT OR OCCURRENCE.
IF YOU CLAIM PERSONAL INJURY:b.
C. IF YOU CLAIM PROPERTY DAMAGE:
(1) DESCRIBE THE PROPERTY DAMAGED.
(2) THE PRESENT LOCATION AND TIME WHEN THE PROPERTY MAY BE INSPECTED.
(3)
DATE PROPERTY ACQUIRED.
(4)
(5)
(6) DESCRIPTION OF DAMAGE.
(7) HAS THE DAMAGE BEEN REPAIRED? IF SO, BY WHOM, WHEN AND COST OF REPAIRS.
(8) ATTACH EACH ESTIMATE OF REPAIR COSTS TO THIS FORM.
(9) SET FORTH IN DETAIL THE LOSS CLAIMED BY YOU FOR PROPERTY DAMAGE.
(5) SET FORTH ANY AND ALL OTHER LOSSES OR DAMAGE CLAIMED BY YOU.
COST OF PROPERTY
VALUE OF PROPERTY AT TIME OF ACCIDENT:
$
$
SET FORTH IN DETAIL ALL OTHER ITEMS OF LOSS OR DAMAGES CLAIMED BY YOU AND THE METHOD BY WHICH YOU MADE
THE CALCULATION.
d.
5.
6. HAVE YOU MADE A CLAIM AGAINST ANYONE ELSE FOR ANY OF THE LOSSES OR EXPENSES CLAIMED IN THIS NOTICE?
IF YES, SET FORTH THE NAME AND ADDRESS OF ALL PERSONS AND INSURANCE COMPANIES AGAINST WHOM YOU HAVE
MADE SUCH CLAIMS:
7. ARE ANY OF THE LOSSES OR EXPENSES CLAIMED HEREIN COVERED BY ANY POLICY OF INSURANCE?
FOR EACH SUCH POLICY, STATE THE NAME AND ADDRESS OF THE INSURANCE COMPANY, POLICY NUMBER AND BENEFITS
PAID OR PAYABLE
8. HAVE YOU RECEIVED OR AGREED TO RECEIVE ANY MONEY FROM ANYONE FOR THE DAMAGES CLAIMED HEREIN?
IF YES, SET FORTH THE DETAIL OF SUCH AGREEMENT.
FULL COPIES OF ALL APPRAISALS AND ESTIMATES OF PROPERTY DAMAGE CLAIMED BY YOU.
COPIES OF ALL WRITTEN REPORTS OF ALL EXPERT WITNESSES AND TREATING PHYSICIANS.
9. THE FOLLOWING ITEMS MUST BE SUBMITTED WITH THIS NOTICE:
(1) COPIES OF ITEMIZED BILLS FOR EACH MEDICAL EXPENSE AND OTHER LOSSES AND EXPENSES CLAIMED.
(2)
(3)
(4) A LETTER FROM YOUR EMPLOYER VERIFYING YOUR LOST WAGES. IF SELF-EMPLOYED, A STATEMENT SHOWING THE
CALCULATION OF YOUR CLAIMED LOST INCOME.
I HEREBY CERTIFY THAT THE FOREGOING STATEMENTS MADE BY ME ARE TRUE. THAT THE ATTACHED STATEMENTS, BILLS, REPORTS AND
DOCUMENTS ARE THE ONLY ONES KNOWN TO ME TO BE IN EXISTENCE AT THIS TIME. 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
YES NO
THE AMOUNT OF THE CLAIM.
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Notice of Claim Instructions (The State of New Jersey)

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Completed 13 October 2020

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