AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY N/A

AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY N/A

Attorney-At-Law Other

If Other, State Relationship

Are you protected by Daniel’s Law?

Claimant Information

First Name

State

Relationship to Claimant

Number of Dependents

State

Phone #

Middle Name

Correspondence Information

Mailing Address

City

Work Phone #

City

Email Address

Date of Birth

Address

Relationship

ZIP

Notices and correspondence in connection with this claim are to be sent to a person other than the claimant

ZIP

Last Name

Name

Marital Status

Mailing Address

Incident Location Diagram

Agency Address(es)

Employee Address if known

Name for Township Agency that you claim caused your damage/injury

Names of the employees who you claim were at fault

Witnesses Names

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 Township agency/employee that caused damages

Witnesses Address

Police officers/departments who investigated the accident

EDIT

Property Damage

Personal Injury

Wages and Income Lost

Insurance Claim Info

Attachments

ALL 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

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.