State of Nevada
Potential Liability Incident Report
INSTRUCTIONS:
State Agency should use this form to report potential liability claims against the State
This “Incident Report” should be sent ASAP to:
Claims Manager, Office of the Attorney General
• Interdepartmental Mail, or
• Via fax to 775-684-4601, or
•
DMV Legal/Tort Claims, 555 Wright Way, Carson City, NV 89711
If an individual wishes to make a formal claim against the State, the individual should contact
the Office of the Attorney General at TEL: 775-684-1252 or 775-684-1263; FAX 775-684-4601.
The Attorney General’s office will send the appropriate form to the injured/damaged party
PLEA
SE NOTE: Do not
use this form to report injuries of State employees.
A Worker’s Compensation injury report must be filed in those instances.
Please type or print clearly
Name of Injured/Damaged Party:
Mailing Address:
Telephone #: Date of Incident: Time:
Location where incident occurred (include street address):
Department: _____________________________________________________
Budget Account:Division: ________________________
Contact Person: Title: Telephone #:
TC-1 Claim form provided to injured/damaged party? Yes No
htt
p://ag.nv.gov/uploadedFiles/agnvgov/Content/Complaints/2018-10_TC1_Claim_Form.pdf
Please provide a detailed description of what happened and attach all supporting documentation you
may have. (Attach additional pages/photographs, if necessary):
Form completed by: Date:
TC-2 (Form revised 10/18)
Office of the Attorney General
