HomeMy WebLinkAboutTort Claim Wells-Gee Notice of Tort Claim
FOR PROPERTY DAMAGE OR BODILY INJURY
This form is to be completed by the claimant and is a requirement that if used, be presented to and filed with the
clerk or secretary of the public entity involved. This form is being provided as a courtesy to assist you in filing your
claim. Providing this form to you is not an admission, nor shall it be construed to be an admission, of liability or an
acknowledgement of the validity of a claim by the political subdivision. Legal requirements for filing claims can be
found in the Idaho Code: Title 6. Chapter 9. All claims must be filed promptly and in writing.
CLAIMANT INFORMATION: (PLEASE PRINT) ?
1. Full Name: S p �} , 1/Vl C�b� l r `: t"h U� G i ,-
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2. Current Address/City/State/Zip:
4. Claimant phone: E-mail,
5.Address for six months prior to the date of damage or injury:
6. Date of Incident: 12-hi Location:
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7. Time of Incident: G . 0a r .Ip.m. (circle one)
8. DESCRIBE IN DETAIL WHAT DAMAGE OR INJURY OCCURRED: (Attach additional documentation if necessary)
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I hereby certify that I have read the above information and it is true and correct to the best of my knowledge.
I hereby make a claim against l
a public entity)
for .L� 1 l 5 in the amount of: G' ( n
IMPORTANT: If you were injured and you are on Medicare/Medicaid, please fill out the following as required by
42 U.S. C. 1395.
Date of Birth: SSN: Medicare/Medicaid Number:
Signature: r' / Date: G/ L/ a
Per Idaho Statute Title 41,Chapter 13: 41-1331-Any person who knowingly,and with intent to defraud or deceive any insurance company.files a
statement of claim containing any false.incomplete,or misleading information is guilty of a felony. "Statement"includes,but is not limited to,any
notice,statement,proof of loss.bill of lading.receipt for payment.invoice,account estimate of property damages,bill for services,diagnosis,
prescription,hospital or doctor records.x-ray test results,or other evidence of loss,injury,or expense.