ACCASBOJIF, BCIPJIF, & GCSSDJIF CLAIM COORDINATOR...

SCHOOL POOL FOR EXCESS LIABILITY LIMITS JOINT INSURANCE FUND

ACCASBOJIF, BCIPJIF, & GCSSDJIF

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ACCASBO

BCIP GCSSD SEJIF

CLAIM COORDINATOR MANUAL

REVISED OCTOBER 2013

Section 6 WE ARE BEING

SUED – TORT CLAIM

FORM ACTIONS

LAW OFFICES Louis J. Greco

CERTIFIED CIVIL TRIAL ATTORNEY

800 Route 50, Suite 2B Mays Landing, NJ 08330

(609) 625-2300 ∙ FAX (609) 625-2340

MEMORANDUM ____________________________________________________

TO: Fund Trustees and Claim Coordinators Representing Member School

Districts

FROM: Louis J. Greco, Esquire Fund Solicitor

RE: Procedures for Handling Tort Claims for ACCASBO/BCIP/GCSSD Joint Insurance Funds

DATE: July 18, 2012

________________________________________________________________________

The Board of Trustees of the Atlantic and Cape May Counties Association of School Business Officials Joint Insurance Fund (ACCASBOJIF), Burlington County Insurance Pool Joint Insurance Fund (BCIPJIF) and Gloucester, Cumberland, Salem School Districts (GCSSDJIF) have established certain uniform procedures for the member Boards of Education to handle claims filed against them. It is the purpose of this memorandum to review the applicable procedures for the handling of tort claims so that all claims are handled promptly and efficiently.

Attached to this memorandum is a thirteen page “Notice of Tort Claim” form. This form will be used any time a claimant (third party) asserts the school district caused his/her damages. The Notice of Tort Claim form must be adopted by your Board of Education via a resolution adopting it as the Board’s official form. A sample resolution is attached. Personalized forms containing your Board of Education’s address will be mailed under separate cover.

Under the law (the Tort Claims Act), we are entitled to require the disclosure of information related to the claim, including information that will enable us to evaluate both liability and damages. The failure of a claimant to provide the requested information on our form in a timely manner can protect the Board of Education against the claim by resulting in the dismissal of the claim. The use of the official form may not win every case for us, but it will give us an additional basis for defending litigation if the claimants have not filed the claim properly and if they have not provided the information by the official form once they have been notified about the form.

In most instances, the first contact you will have will be a letter from an attorney asserting a claim against the Board of Education or against a Board of Education employee. When you receive information from a third party you should do the following:

• Whenever a Notice of Tort Claim or a letter asserting a claim against the Board of Education or against a Board of Education employee is received by the Board of Education, it should be date stamped to show the date on which it was received. [Please note: whenever there is a difference of more than a few days between the postmark on the envelope conveying the initial notice to you and the date that is shown on the Notice or the cover letter, it would be useful to keep the envelope and to provide us with a photocopy of it. We have found several occasions where a Notice is dated on one date and received several weeks later. In that instance, it is very useful to have the envelope showing the date mailed, so that a claimant cannot back date a Notice to comply with statutory deadlines.]

• A copy of the notice should be sent to both Qual-Lynx, the Claims Administrator for the Fund and to me as the Solicitor for the Fund using the tort transmittal form attached to this memorandum.

• At the time you transmit the notice to our offices, kindly provide each of us with whatever information you may have on the incident giving rise to the claim, i.e., internal accident reports, police reports, copies of documents, internal contact person, etc., as that will enable us to get a handle on the claim quickly.

• When the initial contact is received, you should notify the claimant or the attorney for the claimant, by certified mail, return receipt requested, that the claim must be filed on a specific form adopted by the Board of Education for that purpose. A sample format for a responsive letter is attached for your use. A copy of the officially adopted Tort Claim Form should be enclosed with the response letter.

• Once the return receipt is returned, you should retain it in your records, in case we need it at some future time to prove that the claimant was given notice.

There should be no exceptions to this procedure. Just because you may believe that there is no basis for the claim, because it happened outside of the normal school activities, or for any other reason, does not mean that the procedure should not be followed. The Board of Education or an employee of the Board of Education may still be named in the resulting litigation filed by the claimant and it is then too late to [1] gather the necessary information that might have protected the Board of Education or the employee early in the claim process or [2] raise defenses based on the failure of the claimant to comply with the New Jersey Tort Claims Act.

When the completed Notice of Tort Claim form has been returned to you, it should be date stamped to show the date that it was received and copies should be sent to Qual-Lynx and to me so that our information will be as complete as possible regarding the claim.

When a Summons and Complaint is received or when a Notice of Motion is received, or any document that appears to involve a court proceeding, most likely in the New Jersey Superior Court or the United States District Court, that document should be transmitted immediately to Qual-Lynx and to me, as it may require immediate action and the assignment of defense counsel. The receipt of court documents justifies using the telefax to immediately get the documents to Qual-Lynx and to me.

Appropriate telefax numbers are:

Louis J. Greco, Esquire (609)-625-2340 Qual-Lynx Associates (609)-926-9270

When a Summons and Complaint is received, that is not the time to send out the form letter on the Notice of Tort Claim procedures. Even if the Summons and Complaint is your first notice of the claim, do not send out the form letter on the Notice of Tort Claim procedures. Rather, fax the Summons and Complaint to Qual-Lynx and to me, as outlined above. You should keep a log of claims received for convenient reference to assist you in verifying that the claim was received and that the response was properly handled.

If you have any questions regarding the handling of claims, please do not hesitate to ask.

NOTICE OF TORT CLAIM ACTION CHECKLIST

[ ] RECEIPT of letter from claimant or claimant’s attorney • Date stamp the letter • Save the envelope if there is a difference of more than a few days between the

postmark on the envelope and the date on the letter

[ ] SEND Notice of Tort Claim Form to claimant or claimant’s attorney • Cover letter from district • Notice of Tort Claim form • Sent certified mail, return receipt requested

[ ] COMPLETE Liability & Auto Physical Damage Loss Claim Reporting Form

[ ] SEND letter from claimant or claimant’s attorney using Tort Transmittal Form to • Qual-Lynx, Claims Administrator • Louis J. Greco, Esquire

[ ] PROVIDE Qual-Lynx and Greco with • Internal accident reports • Incident report • Liability & Auto Physical Damage Loss Claim Reporting Form • Police reports • Internal contact person • Other information that may assist

[ ] RECEIPT of return receipt card (green card) • Retain it in your records

[ ] RECEIPT of Completed Notice of Tort Claim Form • Date stamp the completed tort form • Copies of the form should be sent to Qual-Lynx and Greco

[ ] RECEIPT of Summons and Complaint • Fax to Qual-Lynx (609)-926-9270 • Fax to Greco (609)-625-2340

TORT TRANSMITTAL FORM

District Address Date:___________________ To: � Qual-Lynx � Internal Distribution {if Appropriate} 100 Decadon Drive � _____________________________

Egg Harbor Twp., NJ 08234 {Name, Title, Telephone Number} Fax: 609-926-9270 � Email: [email protected] {Name, Title, Telephone Number} � {Name, Title, Telephone Number}

� Louis J. Greco, Esquire, 800 Route 50, Suite 2B, Mays Landing, NJ 08330

Fax: 609-625-2340; Email: [email protected] RE: � Atlantic and Cape May Counties Association of School Business Officials Joint Insurance Fund � Burlington County Insurance Pool Joint Insurance Fund � Gloucester, Cumberland, Salem School Districts Joint Insurance Fund

Name of Claimant: _______________________________________________________ Date of Loss/Accident: ____________________________________________________ JIF Claim Number: _______________________________________________________

Enclosed please find the following: � Initial Notice of Tort claim received on _______________________________________ (Include photocopy of envelope showing postal date stamp) � Copy of response, sent on __________________________ by certified mail, return

receipt requested, with the official Notice of Tort Claim form. � Reports on the incident giving rise to the claim. � Official Notice of Tort Claim Form, received on ________________________________ � Summons and Complaint, received on ________________________________________ � _________________________________, received on ___________________________ � _________________________________, received on ___________________________ Very truly yours, ________________________________________________________________ Signature/Title

District Letterhead Date: Dear _____________:

Your recent communication in which you indicate an intention to assert a claim against the Board of Education or against an official or employee of the Board of Education of the <District Name> has been received.

In accordance with New Jersey law, the Board of Education has adopted an official form which is to be completed by any individual seeking to assert a claim against the Board of Education or against any official or employee of the Board of Education.

A copy of the required Notice of Tort Claim form is enclosed for your completion. Kindly complete this form and return it to my office within 90 days after the incident giving rise to the claim. It is important that you complete this form and return it to me as soon as possible to protect your rights in pursuing your claim.

If you have any questions pertaining to this matter, please contact me.

Very truly yours, Board Secretary - Business Administrator

Notice of Tort Claim 92L10 Page 1.

Township of AnyTown Board of Education 123 Main Street ANYTOWN, NEW JERSEY 00000

NOTICE OF TORT CLAIM CLAIMANT INFORMATION Name Telephone Address Date of Birth SSN ATTORNEY INFORMATION (if applicable) Name Telephone Address TeleFAX File No. Send Notices to: Claimant Attorney GENERAL INSTRUCTIONS: Pursuant to the provisions of the New Jersey Tort Claims Act, this Notice of Tort Claim form has been adopted as the official form for the filing of claims against the Board of Education of the Township of AnyTown. The questions are to be answered to the extent of all information available to the Claimant or to his or her attorneys, agents, servants, and employees, under oath. The fully completed Claim Form and the documents requested shall be returned to the Board Secretary - Business Administrator Board of Education of the Township of AnyTown 123 Main Street AnyTown, NJ 00000 NOTE CAREFULLY: Your claim will not be considered filed as required by the New Jersey Tort Claims Act until this completed form has been filed with the Board of Education of the Township of AnyTown. Failure to provide the information requested, including such responses as "To Be Provided" or "Under Investigation" will result in the claim being treated as not being properly filed. Timely Notices of Claim must be filed within 90 days after the incident giving rise to the claim. This form is designed as a general form for use with respect to all claims. Some of the questions may not be applicable to your particular claim. For example, if your claim does not arise out of an automobile accident, questions regarding road conditions might not be applicable. In that event, please indicate "Not Applicable".


If you are unable to answer any question because of a lack of information available to you, specify the reason the information is not available to you. If a question asks that you identify a document, it will be sufficient to furnish true and legible copies. Where a question asks that you "identify all persons," provide the name, address and telephone number of the person. If you need more space to provide a full answer, attach supplementary pages, identifying the continuation of the answer with the number of the applicable question. DEFINITIONS: "Claimant" shall refer to the person or persons on whose behalf the Notice of Claim has been filed with the Board of Education of the Township of AnyTown. "Documents" shall refer to any written, photographic or electronic representation, and any copy thereof, including, but not limited to, computer tapes and/or disks, videotapes and other material relating to the subject matter of the claim. "Person" shall include in its meaning a partnership, joint venture, corporation, association, trust or any other kind of entity, as well as a natural person. "Public Entity" shall refer to the Board of Education of the Township of AnyTown along with any agent, official or employee of the Board of Education against whom a claim is asserted by the Claimant. NOTE that the questions are divided into sections relating to the claimant, the claim, property damage, personal injury and the basis for the claim against the public entity or a public employee. If the claim involves only property damage, then the portion on personal injuries need not be answered. Just enter as the answer to Question 12 "No personal injuries claimed." If the claim involves no property damage, then the portion on property damage need not be answered. Just enter as the answer to Question 11 "No property damage claimed."


INFORMATION ON THE CLAIMANT 1. Provide the following information with respect to the Claimant: a. Any other name by which the Claimant has been known. b. Address at the time of the incident giving rise to the claim. c. Marital Status [at the time of the incident and current] d. Identify each person residing with the claimant and the relation, if any, of the person to the

Claimant. 2. Provide all addresses of the Claimant for the last 10 years, the dates of the residence, the persons

residing at the addresses at the same time as the Claimant resided at the address and the relation, if any, of the person to the Claimant.


INFORMATION ON ALL CLAIMS 3. Provide the exact date, time and place of the incident forming the basis of the claim and the weather

conditions prevailing at the time. 4. Provide the Claimant's complete version of the events that form the basis of the claim. 5. List any and all individuals who were witnesses to or who have knowledge of the facts of the incident

which gave rise to the claim. Provide the full name and address of each individual. 6. Identify all public entities or public employees [by name and position] alleged to have caused the

injury or property damage and specify as to each public entity or employee the exact nature of the act or omission alleged to have caused the injury or property damage.


7. If you claim that the injury or property damage was caused by a dangerous condition of property under the control of the public entity, specify the nature of the alleged dangerous condition and the manner in which you claim the condition caused the injury.

8. If you allege a dangerous condition of public property, state the specific basis on which you claim

that the public entity was responsible for the condition and the specific basis and date on which you claim that the public entity was given notice of the alleged dangerous condition. Statements such as "should have known" and "common knowledge" are insufficient.

9. If you or any other party or witness consumed any alcoholic beverages, drugs or medications within

twelve (12) hours before the incident forming the basis of the Claim, identify the person consuming the same and for each person (a) what was consumed (b) the quantity thereof (c) where consumed (d) the names and addresses of all persons present.

10. If you have received any money or thing of value for your injuries or damages from any person, firm

or corporation, state the amounts received, the dates, names and addresses of the payors. Specifically list any policies of insurance, including policy number and claim number, from which benefits have been paid to you or to any person on your behalf, including doctors, hospitals or any person repairing damage to property.


11. If any photographs, sketches, charts or maps were made with respect to anything which is the subject matter of the claim, state the date thereof, the names and addresses of the persons making the same and of the persons who have present possession thereof. Attach copies of any photographs, sketches, charts or maps.

12. If you or any of the parties to this action or any of the witnesses made any statements or admissions,

set forth what was said; by whom said; date and place where said; and in whose presence, giving names and addresses of any persons having knowledge thereof.

13. State the total amount of your claim and the basis on which you calculate the amount claimed. 14. Provide copies of all documents, memoranda, correspondence, reports [including police reports], etc.

which discuss, mention or pertain to the subject matter of this claim. 15. Provide the names and addresses of all persons or entities against whom claims have been made for

injuries or damages arising out of the incident forming the basis of this claim and give the basis for the claim against each.


PROPERTY DAMAGE CLAIMS 16. If your claim is for property damage, attach a description of the property damage and an estimate of

the costs of repair. If your claim does not involve any claim for property damage, enter "None". If your claim is for property damage only, initial here and proceed directly to page 11 and

sign the Certification.


PERSONAL INJURY CLAIMS 17. Was any complaint made to the public entity or to any official or employee of the public entity. State

the time and place of the complaint and the person or persons to whom the complaint was made. 18. Describe in detail the nature, extent and duration of any and all injuries. 19. Describe in detail any injury or condition claimed to be permanent. 20. In confined to any hospitals, state name and address of each and the dates of admission and

discharge. Include all hospital admissions prior to and subsequent to the alleged injury and give the reason for each admission.


21. If x-rays were taken, state (a) the address of the place where each was taken (b) the name and address of the person who took them (c) the date when each was taken (d) what each disclosed (e) where and in whose possession they now are. Include all x-rays, whether prior to or subsequent to the alleged injury forming the basis of the claim.

22. If treated by doctors, including psychiatrists or psychologists, state (a) the name and present address

of each doctor (b) the dates and places where treatments were received (c) the nature of the treatment (d) the date of last treatment or, if treatments are continuing, the schedule of continuing treatments. Provide true copies of all written reports rendered to you or about you by any doctors who you propose to have testify on your behalf.

23. If you have any physical impairment which you allege is caused by the injury forming the basis of

your claim and which is affecting your ordinary movements, hearing or sight, state in detail the nature and extent of the impairment and what corrective appliances, support or device you use to overcome or alleviate the impairment.

24. If you claim that a previous injury has been aggravated or exacerbated, describe the injury and give

the name and present address of each doctor who treated you for the condition, the period during which treatment was received and the cause of the previous injury. Specifically list any impairment, including use of eyeglasses, hearing aid or similar device, which existed at the time of the injury forming the basis of the claim.


24A. List all injuries in the last 5 years and specify which injuries included a claim. 25. If any treatments, operation or other form of surgery in the future has been recommended to alleviate

any injury or condition resulting from the incident which forms the basis of the claim, state in detail (a) the nature and extent of the treatment, operation or surgery (b) the purpose thereof and the results anticipated or expected (c) the name and address of the doctor who recommended the treatments, operation or surgery (d) the name and address of the doctor who will administer or perform the same (e) the estimated medical expenses to be incurred (f) the estimated length of time of treatments, operation or surgery, period of hospitalization and period of convalescence (g) all other losses or expenditures anticipated as a result of the treatments, operation or surgery (h) whether it is you intention to undergo the treatments, operation or surgery and the approximate date.

26. Itemize any and all expenses incurred for hospitals, doctors, nurses, x-rays, medicines, care and

appliances and indicate which expenses were paid by any insurance coverage. 27. If employed at the time of the alleged injury forming the basis of the claim state (a) the name and

address of the employer (b) position held and the nature of the work performed (c) average weekly wages for the year prior to the injury (d) period of time lost from employment, giving dates (e) amount of wages lost, if any. List any sources of income continuation or replacement, including, but not limited to, worker's compensation, disability income, social security and income continuation insurance.

28. If other loss of income, profit or earnings is claimed, state (a) total amount of the loss (b) give a

complete detailed computation of the loss (c) the nature and dates of loss.


29. If you are claiming lost wages (a) the date that the employment began (a) the name and address of the

employer (c) the position held and the nature of the work performed (d) the average weekly wages. Attach copies of pay stubs or other complete payroll record for all wages received during the past year.

DOCUMENT REQUEST: Produce all documents identified in your answers to the above questions. CERTIFICATION I hereby certify that the information provided is the truth and is the full and complete response to the

questions, to the best of my knowledge.

Signature of Claimant Dated:


AUTHORIZATION FOR RELEASE OF EMPLOYMENT RECORDS TO: Date: RE: Patient's Name Address Social Security Number Claim Number You are hereby authorized and requested to disclose, make available and furnish to: all information relating to my employment, including, but not limited to, my job title, assigned duties, compensation, benefits, attendance, and sick leave and to permit him or her to inspect and make copies or abstracts thereof. A photocopy of this release form, bearing a photocopy of my signature, shall constitute your authorization for the release of the information in accordance with the request made to you. ____________________________________ Signature


AUTHORIZATION FOR HEALTH INFORMATION DISCLOSURE PATIENT INFORMATION

(please print)

Patient Name: _____________________________________________________________ DOB: _____________ PatientAddress:_______________________________________________________________________________ City: ____________________________________________ State: _________________ Zip: _______________ I hereby authorize:____________________________________________________________________________

(Name of physician’s office/medical practice disclosing information)

REQUESTOR/RECIPIENT INFORMATION

Please disclose the following protected health information to: Qual-Lynx Phone: 609-653-8400

100 Decadon Drive Fax: 609-926-9270 Egg Harbor Township, NJ 08234

Please indicate the information or types of information to be disclosed: any and all medical records in your possession, including but not limited to any and all office notes, medical records, reports, diagnostic studies, hospital records, operative reports, psychiatric and/or psychological records, bills etc. Specify dates (or date range) if applicable: This request is for the purpose of investigation. I understand that I have the right to revoke this authorization at any time. I understand that my revocation must be in writing and addressed to the privacy officer of the above named facility authorized to make this disclosure. I understand that the revocation does not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire in two years or on the following date: _____________________________. I understand that any disclosure of information may be subject to re-disclosures by the recipient and may no longer be protected by federal state law. I understand that I need not sign this authorization to assure treatment. I understand that I may inspect and/or copy the information to be disclosed. I understand that authorizing this disclosure is voluntary. I understand that if I have any questions about disclosure of my health information, I may contact the privacy officer at the facility listed above that is authorized to disclose this information and request a copy of this authorization. I understand that my health record may include information pertaining to the treatment of drug and alcohol abuse, mental illness, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV), sexually transmitted diseases, tuberculosis or genetics. IF YOU DO NOT WISH THIS INFORMATION TO BE RELEASED, PLEASE INITIAL: DO NOT RELEASE __________ Finally, I understand that I may revoke this authorization in writing at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization. A copy of this signed form will be provided to the claimant patient. Photocopies of this Authorization carry the same authority as the original. ________________________________________________________ ____________________________ Signature of Patient of Authorized Representative Date ________________________________________________________ ____________________________ Description of Representative’s Authority Signature of Witness (witness signature required) File # ___________


SECTION I 1. FULL NAME (Please Print exactly as it appears on your Medicare or Social Security Card.

2. ADDRESS

3. HOME TELEPHONE NUMBER _ _

4. DATE OF BIRTH (01/01/1999) 5. SEX

/ / 6. SOCIAL SECURITY NUMBER

- -

The Centers for Medicare & Medicaid Services (CMS) is the federal agency that

oversees the Medicare program. Many Medicare beneficiaries have other insurance in addition to their Medicare benefits. Sometimes, Medicare is supposed to pay after the other insurance. However, if certain other insurance delays payment, Medicare may make a “conditional payment” so as not to inconvenience the beneficiary, and recover after the other insurance pays.

Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA), a new federal law that became effective January 1, 2009, requires that liability insurers (including self-insurers), no-fault insurers, and workers’ compensation plans report specific information about Medicare beneficiaries who have other insurance coverage. This reporting is to assist CMS and other insurance plans to properly coordinate payment of benefits among plans so that your claims are paid promptly and correctly.

We are asking you to the answer the questions below so that we may comply with this law.

MALE FEMALE


7. Are you presently or have you ever been enrolled in Medicare Part A or Part B YES NO

8. MEDICARE CLAIM NUMBER:

SECTION II I understand that the information requested is to assist the requesting insurance arrangement to accurately coordinate benefits with Medicare and to meet its mandatory reporting obligations under Medicare law. Claimant Name (Please Print) Claim Number _________________________ __________________________ Name of Person Completing This Form If Claimant is Unable (Please Print) ________________________________________________________________ Signature of Person Completing This Form Date _____________________________________ ______________ If you have completed Sections I and II above, stop here. If you are refusing to provide the information requested in Sections I and II, proceed to Section III. Section III _______________________________ _____________________ Claimant Name (Please Print) Claim Number For the reason(s) listed below, I have not provided the information requested. I understand that if I am a Medicare beneficiary and I do not provide the requested information, I may be violating obligations as a beneficiary to assist Medicare in coordinating benefits to pay my claims correctly and promptly. Reason(s) for Refusal to Provide Requested Information: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ _____________________________________ ________________ Signature of Person Completing This Form Date

Please review this picture of the Medicare card to determine if you have, or have ever had, a

similar Medicare card

Liability & Automobile Physical Damage Loss Claim Reporting Form Page 1 of 7

ACCASBOJIF BCIPJIF GCSSDJIF

This is a claim form for developing relevant claim information and in no way constitutes, defines or declares coverage.

I. General Information District Name: ___________________________________________________________________

Campus or Location Name: _________________________________________________________

Address: ________________________________________________________________________

Contact Name: ___________________________________________________________________

Phone Number: __________________ Fax Number (if any): ________________________

Reported By: ____________________ Reported To: _______________________________ Date: _____________________ Date: _______________________________

Date loss occurred? _________________________________________________________

Was a Tort Notice Questionnaire sent to the person(s) who are claiming an injury and or loss of property?

Yes, (please attach a copy of your transmittal letter) No, (explain why not)________________________________________________________

Type Of Liability Claimed\Alleged General Liability Claim

Person(s) claiming they were injured or their property was damaged, or both, while on

district owned property or at a district related event off premises but not involving an

automobile accident. If checked complete Section II, General Liability, beginning on page 2

and ending on page 3. Automobile Liability and/or Automobile Physical Damage Claim

Person(s) claiming they were injured or their property was damaged, or both, as a result of

an automobile related accident in which a district automobile or vehicle was alleged to be

involved. If checked skip Section II and go to Section III, Automobile Liability, beginning

on page 4 and ending on page 7.

Educator’s Legal Liability

Person claiming non-bodily injury/non-property damages arising from the wrongful act of a school administrator or employee. Forward documentation of claim via Claim Transmittal Form to Qual-Lynx.




II. General Liability Liability For Bodily Injury, Property Damage or Both, Which Is Alleged To Have Happened To

Someone While On District Owned Premises Or At A District Event Off Campus But Not Involving An Automobile.

How many persons claim to have been injured? - _______.

Please list each persons name, address and telephone below:

Persons Name Address Phone Number ___________________ ____________________________ ______________________

___________________ ____________________________ ______________________

___________________ ____________________________ ______________________

___________________ ____________________________ ______________________

___________________ ____________________________ ______________________

___________________ ____________________________ ______________________

___________________ ____________________________ ______________________

Did injured person(s) receive any type of first aid or medical treatment? Yes No

If yes, please describe care for each individual: ___________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Was a report of any kind made to local authorities by you, the district or the injured party(ies)? Yes No If yes, please describe below:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________




General Liability (continued)

Does the injured party (do the injured parties) claim that their property was damaged in the accident? Yes No If yes, please complete the following questions for each person claiming property damage:

• Name of property owner: __________________________________________________

• Address of property owner: ________________________________________________

______________________________________________________________________

• Telephone number of property owner: _______________________________________

• Description of damaged property: ___________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

• Please provide a serial or other ID number if known: ____________________________

• Description of how property allegedly was damaged: ____________________________

______________________________________________________________________

______________________________________________________________________

• Address of place where property can be seen: __________________________________

______________________________________________________________________

• Estimated value of property lost (if known):$ __________________________________

• Is there any other insurance on the other property? Yes No

• If Yes, please provide name of insurance carrier and policy number: ________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________




III. Automobile Liability/Physical Damage Liability For Bodily Injury, Property Damage or Both, Which Is Alleged To Have Happened To

Someone As A Direct Result Of An Automobile Accident. Questions on this page are to be answered about the involved district vehicle and driver. Make, model and year of involved district vehicle: ____________________________________

Vehicle identification number (VIN #) of involved district vehicle: _______________________

Involved district vehicle’s license plate number:______________________________________

Involved vehicle’s owners name if other than district: _________________________________

Address: __________________________________________________________

Phone Number: __________________________________________________________

Is the involved vehicle leased? Yes No

If yes, who is lessor?: ____________________________________________________

Address: __________________________________________________________

Phone Number: __________________________________________________________

Drivers name: __________________________________________________________

Address: ________________________________________________________________

Phone numbers: Home: _______________________ Work: ____________________

Driver’s license number: _________________________ Date of birth: ______________

Is driver an employee of the district? Yes No

If No, explain relationship to district: __________________________________________

_______________________________________________________________________

Was vehicle used with permission? Yes No

If No, explain circumstances: ________________________________________________

_______________________________________________________________________

What was the purpose of the use? _____________________________________________

_______________________________________________________________________

Name of police department accident was reported to: _____________________________

_______________________________________________________________________




Automobile Liability/Physical Damage (continued)

Questions on this page are to be answered about the person or persons who are alleging that they were injured as a result of the automobile accident. How many persons claim to have been injured? - _______.

Please list each persons name, address and telephone below:

Persons Name Address Phone Number ___________________ ____________________________ ______________________

___________________ ____________________________ ______________________

___________________ ____________________________ ______________________

___________________ ____________________________ ______________________

___________________ ____________________________ ______________________

___________________ ____________________________ ______________________

___________________ ____________________________ ______________________

Did injured person(s) receive any type of first aid or medical treatment? Yes No

If yes, please describe care for each individual below:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Was a report of any kind made to local authorities by you, the District or the injured party(ies)?

Yes No

If yes, please list name of authorities to which any reports were made providing the address,

telephone number and contact person if known below:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________




Automobile Liability (continued)

Questions on this page are to be answered about the person or persons who are alleging that their vehicle was damaged as a result of the accident. If there is more than one vehicle involved, please complete this page for each one of the non-district owned vehicles.

Owner’s name: ________________________________________________________________

Address: _______________________________________________________________

_______________________________________________________________


Drivers name: _______________________________________________________________

Address: _______________________________________________________________

_______________________________________________________________


Driver’s license number: _______________________ Date of birth: ______________

Name of police department accident was reported to: __________________________________

____________________________________________________________________________

Make, model and year of vehicle: _________________________________________________

Vehicle identification number (VIN #): _____________________________________________

Vehicle license plate number: ____________________________________________________

Describe damage to vehicle: _____________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Where can the vehicle be seen? ___________________________________________________

Is there any other insurance on the vehicle? Yes No

If Yes, please provide name of insurance carrier and policy number: ______________________

____________________________________________________________________________

Describe Accident: _____________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

What do you estimate the total cost of the damage to the vehicle to be? $ _________________




Automobile Liability (continued) Was there damage to a district owned vehicle or some other district owned property?

Yes No

If Yes: Complete and attach the First Party Property\Loss Claim Form in addition to completing this form.

If No: Continue on.

Was there damage to property other than an automobile and owned by someone other than the district? Yes No

If Yes: Complete the information requested below for each person or organization claiming such property damage.

If No: You have completed the reporting process and should forward this claim form

on to the Fund’s claim administrator along with a Master Claim Transmittal Form.

Please complete the following questions for each person claiming property damage:

• Name of property owner: __________________________________________________

• Address of property owner: ________________________________________________

______________________________________________________________________

• Telephone number of property owner: _______________________________________

• Description of damaged property: ___________________________________________

______________________________________________________________________

• Please provide a serial or other ID number if known: ____________________________

• Description of how property allegedly was damaged: ____________________________

______________________________________________________________________

• Address of place where property can be seen: __________________________________

______________________________________________________________________

• Estimated value of property lost (if known):$ __________________________________

• Is there any other insurance on the other property? Yes No

If Yes, please provide name of insurance carrier and policy number: ______________________

_________________________________________________________________________

_________________________________________________________________________

ACCASBOJIF, BCIPJIF, & GCSSDJIF CLAIM COORDINATOR...

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