Notice of Tort Claim

Planning & Building Forms

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.

Full Name:*

Current Address:*

Mailing Address (if different):

Phone Number:*

E-Mail:*

Address six months prior to the date of damage or injury:*

Date of incident:*

Time of incident:*

Location:*

Describe in detail what damage or injury occurred:*

Witnesses:*

Phone Number:*

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:*

for:*

Enter other amount: *

Were you injured and are you on Medicare/Medicaid?:*

yes no

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.

Signature:

I acknowledge by my signature that the records sought by this request will not be used for a mailing list or telephone lists and will be follow the regulations as set forth in Idaho Code §74-120.

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Notice of Tort Claim

Planning & Building Forms

Notice of Tort Claim