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CLAIM FOR DAMAGE OR INJURY In order that your claim for damage or injury may receive proper consideration, you must supply the information called for on the attached claim form. All material facts should be stated on this form, as it will be the basis of further action upon your claim. The instructions set forth below should be read carefully before the form is prepared. Fill out this form and print, sign, and date or print this form and complete in ink, sign, and date and then mail to: Office of the County Clerk, County of Hawaii, 25 Aupuni Street, Hilo, Hawaii 96720, or hand - deliver to Room 1402 of the above address. No faxed or e- mailed forms will be accepted. Claim forms are also available at the Office of the County Clerk. Initial questions may be directed to (808)961 -8255. Instructions Claims for damage to or for loss or destruction of property, or for personal injury, must be signed by the owner of the property damaged or lost, or by the injured person. If by reason of death or disability, or for reasons satisfactory to the County of Hawaii, the foregoing requirements cannot be fulfilled, the claim may be filed by a duly authorized agent or other legal representative, provided evidence satisfactory to the County is submitted with the claim form establishing the agent's or representative's authority to act on behalf of the claimant. The basis for liability in the amount claimed should be substantiated with competent evidence as follows: (a) In support of a claim for personal injury or death, the claimant must submit a written report by the attending physician showing the nature, extent and cause of injury, the nature, extent and justification for the treatment chosen, the degree of permanent disability, if any, the prognosis, and the period of hospitalization or incapacitation attaching itemized bills for medical, hospital, or burial expenses actually incurred. (b) In support of a claim for damage to property which has been or can reasonably be repaired, the claimant must submit at least two itemized signed statements or estimates by reliable disinterested concerns, and if payment has been made, the itemized, signed receipts evidencing payment. (c) In support of a claim for damage to property which is not repairable, or if the property is lost or destroyed, the claimant must submit statements as to the original cost of the property, the date of purchase, and the value of the property at the time of the loss. Such statements should be confirmed by disinterested, competent persons, preferably reputable dealers or officials familiar with the type of property damaged, or by two or more competitive bidders, and should be certified as being just and correct. YOUR CLAIM WILL NOT BE CONSIDERED UNTIL THE REQUIRED SUPPORTING DOCUMENTS ARE PROVIDED BY YOU 7/10