Notice of Tort Claim For Property Damage And/Or Personal Injury
Notice of Tort Claim For Property Damage And/Or Personal Injury
INSTRUCTIONS:
Anyone who has a claim for personal injury or property damage against the State of Indiana must either use this form to file a claim or
make the claim in writing as prescribed in Indiana Code 34-13-3. Immunities are listed on the back of this form.
1. If applicable, include copies of accident/incident report, vehicle registration, paid receipts for repair or two (2) estimates for
repair, medical reports, photographs and any additional documentation in reference to this matter.
2. Each person who had a loss should file a separate form.
3. Sign and date this form.
4. State statute requires the claim be delivered in person or be sent via Certified or Registered mail to the address in the upper
right corner above.
5. Do not delay making your claim. Indiana law gives you two hundred seventy (270) days after the loss to make a claim and it must
comply with Indiana Code 34-13-3.
6. Keep a copy of your claim form, receipts, bills and certified/registered mail receipt.
7. If your claim is properly filed, the Office of the Attorney General will investigate it and will notify you in writing within ninety (90)
days of receipt if your claim is approved. A claim is denied if not approved within ninety (90) days.
8. The filing of this claim is part of a legal process. If you have any questions about the right way to file a claim, please contact an
attorney of your choice. The states attorneys are not authorized by law to assist you with filing this claim. For your information a
list of actions, or conditions, resulting in non-liability pursuant to Indiana Code 34-13-3 are shown on the back of this form.
CLAIMANT INFORMATION
Name
Home Telephone
Address at Time of Loss (number and street, city, state, and ZIP code)
Email Address
Work Telephone
Cellular Telephone
Issuing State
Issuing State
LOSS INFORMATION
Date of Loss (m/d/yy)
Time of Loss
AM
PM
Exact Location of Loss (include town, street & nearest crossroad)
Loss County
Alleged Negligence
Please read: I swear and affirm under the penalties for perjury that the foregoing information is true and correct to the best of my knowledge and belief.
Claimants Signature
Date (m/d/yy)