{[ADDR]}
Law Department - Room 201
{[CITY]}, {[STATE]} {[ZIP]}
908-820-4009
www.elizabethnj.org
Personal Injury
{[PNAME]}
Other
Claim For Damage
  • This claim form must be filed within ninety (90) days of accident or occurrences or you may forfeit your rights ( N.J.S.A. 59:1-1, et seq.
  • Please be aware that this form will time out after 10 minutes. We recommend reviewing the attachments section and preparing any relevant documents before you start filling it out.
Property Damage
Property Damage (Vehicle)
{[CNAME]}
Department of Law
If Other: Explain
  • Contacts
  • Accident Information
  • Property Damage
  • Personal Injuries
  • Wages Lost
  • Insurance Claims
  • Attachments
  • Signature
If Other, State Relationship
Are you protected by Daniel’s Law?
Claimant Information
First Name
State
Relationship to Claimant
Social Security #
State
Phone #
Middle Name
Correspondence Information
City
Work Phone #
City
Email
Date of Birth
Address
Phone #
ZIP
Email
Notices and correspondence in connection with this claim are to be sent to a person other than the claimant
ZIP
Last Name
Name
Address
Incident Location Diagram
Agency Address
Employee(s) Address if known
Name for city Agency that you claim caused your damage/injury
Name(s) of the employee(s) who you claim were at fault
Witness(es) Name(s)
Police officers' addresses who investigated the accident
Accident Information
Where did this accident take place?
Accident Date & Time
Accident Description
Negligence or wrongful acts of the public entity and public employees that caused damages.
Witness(es) Address(es)
Police officers/departments who investigated the accident
Property Damage
Personal Injury
Wages and Income Lost
Insurance Claim Information

 General Claim Attachments

  1. Incident Documentation

    • Police/Accident Report: Evidence of incident.
    • Estimate of Damages: Cost estimation for repairs.
    • Pictures of Damages: Visual proof of damage, possibly showing the incident location.

  2. Financial Documentation

    • Receipts for Out-of-Pocket Expenses: Proof of direct costs.
    • Insurance Declaration Page: Verification of insurance coverage.

Medical-Related Claims

  1. Medical Treatment and Disability

    • Written Reports from Attending Physician(s)/Dentist: Description of injury, treatment, disability status, prognosis, etc.
    • Itemized Medical Bills and Receipts: Breakdown of medical and hospital expenses.
    • Documentation of Lost Income: Evidence of wages lost, employment details, and income affected.
    • Authorization for Release of Personal and Health Information Pursuant to HIPPA: HIPPA Form

  2. Future Treatment Costs

    • Anticipated Expense Documentation: Estimates for required future medical treatments.

Property Damage Claims

  1. Ownership and Repair Documentation
    • Proof of Property Ownership: Ownership details of damaged property.
    • Itemized Repair Receipts/Estimates: Cost analysis and payment records for repairs or replacements.
    • Detailed Property Statement: Including purchase date, price, and salvage value if repair isn’t economical.

Death-Related Claims

  1. Death Certification and Support Documentation
    • Authenticated Death Certificate: Proof of death.
    • Employment and Earnings Documentation: Decedent’s job, salary, and employment history.
    • Survivor Information: List of dependents with relationship and birth details.
    • Support Dependency Statement: Level of financial dependency of each survivor.
    • Physician and Mental Condition Reports: Details of health conditions before death.
    • Burial Expense Bills: Itemized costs related to burial.

Additional Required Attachments for all Claims

  1. Insurance Information
    • Insurance Policy Information: List of insurance providers and policy numbers that might cover the claim.
  2. Additional Visual Evidence
    • Pictures, Diagrams, and Related Documents: For illustrating the accident location, loss details, and property condition.
Attachments
Type Full Name :
Sign With Hand
ALL THE INFORMATION REQUESTED IN THIS FORM MUST BE PROVIDED SO THAT FAIR AND FULL DISCLOSURE OF INFORMATION NECESSARY TO THE ORDERLY AND EXPEDIENT ADMINISTRATIVE DISPOSITION OF THE CLAIM MAY BE HAD. UNDER THE SCHEME OF THE NEW JERSEY TORT CLAIMS ACT, A GOVERNMENTAL ENTITY IS AFFORDED AT LEAST SIX MONTHS FROM THE DATE OF THE RECEIPT OF A COMPLETED FORM REVIEW AND SETTLE MERITORIOUS CLAIMS. FAILURE TO PROVIDE COMPLETE ANSWERS TO ALL QUESTIONS AND/OR THE WITHHOLDING OF INFORMATION MAY RESULT IN FORFEITURE OF THE CLAIMANT'S RIGHTS. (N.J.S.A. 59:8-1, et seq.)
Signature
"Please note that this claim will be sent to QualLinks our third party adjuster, they will assign and adjuster to investigate your claim"
"Please allow 7 to 10 business days"
Applicant Signature
TO WHOM IT MAY CONCERN: I hereby authorize any and all doctors, hospitals or other medical service facilities to release, any and all records, reports and other information concerning the treatment of the claimant named herein.

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, that I am subject to punishment provided by law.