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HomeMy WebLinkAboutClaim for Damage or Injury FormCLAIM 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 PROOF OF LOSS FOR CLAIM FOR DAMAGE OR INJURY* (Attach additional sheets if necessary) Name of Claimant (please provide full name) 2. Address of Claimant (street, city, state, zip code) Mailing Address of Claimant (if different from above address) 3. Telephone Numbers: (residence) (business) 4. Date and Time of Accident: Location of Accident: 5. Amount of Claim: Property Damage $ Personal Injury $ TOTAL $ 6. Description of Accident (Detail known facts and circumstances about the damage or injury. Identify persons and property involved and the cause thereof. Use additional sheets of paper if required.) *PLEASE BE ADVISED THAT FILING OF YOUR CLAIM WITH THIS OFFICE DOES NOT FULFILL YOUR NEED TO FILE A LAWSUIT IF YOU DISAGREE WITH THE DECISION ON YOUR CLAIM, REGARDLESS OF WHETHER YOUR CLAIM IS TIMELY INVESTIGATED AND A REPLY MADE TO YOU WITHIN THE APPLICABLE PERIOD OF LIMITATIONS WHICH MAY BE AS SHORT AS TWO YEARS. 7/10 7. Property Damage: Name of Owner, if other than Claimant Address of Owner, if other than Claimant (street, city, state, zip code) Mailing Address of Owner (if different from above address) Briefly describe kind and location of property and nature and extent of damage. (See instructions for method of substantiating claim.) 8. Personal Injury (State nature and extent of injury which forms the basis of this claim.) 9. Witnesses: Name Address Telephone No. *PLEASE BE ADVISED THAT FILING OF YOUR CLAIM WITH THIS OFFICE DOES NOT FULFILL YOUR NEED TO FILE A LAWSUIT IF YOU DISAGREE WITH THE DECISION ON YOUR CLAIM, REGARDLESS OF WHETHER YOUR CLAIM IS TIMELY INVESTIGATED AND A REPLY MADE TO YOU WITHIN THE APPLICABLE PERIOD OF LIMITATIONS WHICH MAY BE AS SHORT AS TWO YEARS. 7/10 -2- ITEMS #10- #12 PERTAIN TO AUTO CLAIMS. IF THESE DO NOT APPLY, PROCEED TO ITEMS #13, #14, SIGN AND DATE. In order that subrogation claims may be adjudicated, it is essential that you provide the following information regarding the insurance coverage of your vehicle: 10. Do you carry automobile insurance? Yes No Give name and address of insurance company and policy number. 11. Have you filed a claim on your insurance carrier in this instance? Yes No Do you have full coverage or a deductible? What is your deductible? If such claim has been filed, what action has your insurer taken, or what action does it propose to take with reference to your claim? (It is necessary that you ascertain these facts.) 12. Do you carry public liability and property damage coverage? Yes No 13. Have you reported your accident/incident to the police? Yes Report Number Please submit report. No Why? *PLEASE BE ADVISED THAT FILING OF YOUR CLAIM WITH THIS OFFICE DOES NOT FULFILL YOUR NEED TO FILE A LAWSUIT IF YOU DISAGREE WITH THE DECISION ON YOUR CLAIM, REGARDLESS OF WHETHER YOUR CLAIM IS TIMELY INVESTIGATED AND A REPLY MADE TO YOU WITHIN THE APPLICABLE PERIOD OF LIMITATIONS WHICH MAY BE AS SHORT AS TWO YEARS. 7/10 -3- 14. Please provide the following information and materials: a. Verified copies of all bills or expenses claimed to have been incurred as a result of the incident or accident. b. Medical reports detailing the diagnosis, prognosis and causation of any claimed injury, together with a statement as to the nature and extent of permanent injury, if any. Certified appraisals or repair estimates of property damage, if any. d. Verified statement of loss of wages and /or time and /or sick leave used from employer. e. Amount and nature of Workers' Compensation payments, if any. f. Nature and amount of payments received under medical plans, and the name of said medical plan, if any. g. Other: SIGNATURE OF CLAIMANT DATE OF CLAIM *PLEASE BE ADVISED THAT FILING OF YOUR CLAIM WITH THIS OFFICE DOES NOT FULFILL YOUR NEED TO FILE A LAWSUIT IF YOU DISAGREE WITH THE DECISION ON YOUR CLAIM, REGARDLESS OF WHETHER YOUR CLAIM IS TIMELY INVESTIGATED AND A REPLY MADE TO YOU WITHIN THE APPLICABLE PERIOD OF LIMITATIONS WHICH MAY BE AS SHORT AS TWO YEARS. 7/10 n