Instructions for Filing a Claim
CLAIMANT: Name of the titled owner(s) of the vehicle and/or name of the injured party, if any, or in case of real estate, name of property owner(s).
RESPONDENT STATE AGENCY: This is usually the Division of Highways (DOH).
AMOUNT CLAIMED: Actual payment for repairs, if made, or an estimate, may constitute the amount of the damages. If a claimant has insurance which will cover the damages to the vehicle, the claimant may recover only the deductible portion of the insurance. A copy of the insurance abstract is helpful to the Claims Commission. Subrogation claims by insurance companies are not considered by the Claims Commission.
NAME AND ADDRESS OF ATTORNEY OR CLAIMANT: If claimant has an attorney, please complete these lines. If no attorney, claimant must complete the lines under Claimant Information, providing his/her name, address, and telephone number.
FACTS OF YOUR CLAIM: Include the date, time, location, and circumstances of the incident in detail. Include the State Route number and any landmarks nearby, if known. State why the DOH, or other agency, should be liable for the damage.
SIGNATURE: Claim form should be signed by claimant(s).
Submit CLAIM FORM and all INVOICES in TRIPLICATE.
CLAIMANT: Legal, corporate title of the vendor.
RESPONDENT: Name of the State agency which incurred the expense.
ATTORNEY AND/OR CLAIMANT ADDRESS: Name and address of the individual who is responsible for maintaining the information about the claim on behalf of the claimant company. If the claim is contested, the claimant corporation shall be represented by an attorney.
AMOUNT OF CLAIM: Accurate total of the invoices.
STATE THE FACTS OF THE CLAIM CONCISELY: Vendors should denote the fiscal year(s) for the invoices which constitute the claim. Also, attach copies of the invoice(s) and add any explanation for failure of the agency to pay the invoice(s), if known. The amount claimed should be the sum of all invoices. Briefly state what the invoices for merchandise or services represent.
SIGNATURE: Claim form should be signed by an individual with the legal capacity to bring a lawsuit on behalf of the corporation or partnership.