Complete all items - Insert the word NONE where applicable A CLAIM SHALL BE DEEMED TO HAVE BEEN PRESENTED WHEN A FEDERAL AGENCY Any instructions or information necessary in the preparation of your claim will be furnished. upon request, by the office indicated in item #1 on the reverse side Complete regulations pertaining to clams asserted under the Federal Tort Claims Act can be found in Title 28. Code of Federal Regulations. Part 14 Many agencies have Dublished supplemental regulations also If more than one agency is involved, please state each agency The claim may be filed by a duly authonzed agent or other legal representative. provided evidence satisfactory to the Government is submitted with said claim establishing express authority to act for the claimant. A claim presented by an agent or | legal representative must be presented in the name of the claimant If the claim is signed by the agent or legal representative, it must show the title or legal capacity of the person signing and be accompanied by evidence of his/her authonty to present a claim on behalf of the claimant as agent, executor, administrator, parent. guardian or other representative If claimant intends to file claim for both personal injury and property damage, claim for both must be shown in item 12 of this form The amount claimed should be substantiated by competent evidence as follows: (a) in support of the claim for personal injury or death, the claimant should submit a written report by the attending physician, showing the nature and extent of injury. the nature and extent of treatment, the degree of permanent disability, if any, the prognosis, and the period of hospitalization, or incapacitation, attaching itemized bills for medical, hospital, or burial expenses actually incurred. (b) in support of clams for damage to property which has been or can be economically repaired, the claimant should submit at least two itemized signed statements or estimates by reliable, disinterested concerns, or if payment has been made, the itemized signed receipts evidencing payment (c) in support of claims for damage to property which is not economically repairable or if the property is lost or destroyed, the clamant should submit statements as to the original cost of the property, the date of purchase, and the value of the property, both before and after the accident. Such statements should be by disinterested competent persons, preferably reputable dealers or officials familiar with the type of property damaged, or by two or more competitive bidders, and should be certified as being just and correct. (d) Failure to completely execute this form or to supply the requested material within two years from the date the allegations accrued may render your claim “invalid" A claim is deemed presented when it is received by the appropriate agency, not when it is mailed. Failure to specify a sum certain will result in invalid presentation of your claim and may result in forfeiture of your rights. INSURANCE COVERAGE In order that subrogation claims may be adjudicated, it is essential that the claimant provide the following information regarding the insurance coverage of his vehicle or property 15 Do you carry accident insurance? Yes. If yes, give name and address of insurance company (Number, street, city, State, and Zip Code) and policy number = No 16 Have you filed claim on your insurance carrier in this instance, and if so, is it full coverage or deductible? 17 if deductible, state amount 16 If claim has been filed with your carrier, what action has your insurer taken or proposes to take with reference to your claim? (It is necessary that you ascertam these facts, Do you carry public liability and property damage insurance? Yes If yes give name and address of insurance carrier (Number, street. city, State, and Zip Code) No SF 95 (Rev 7-85. BACK How a Claim is Handled under the FTCA Step-by-Step Narrative on Administrative and Judicial FTCA Claims Process Universe of Claims and FTCA Coverage Charts Center for Health Policy Research Administrative and Judicial FTCA Claims Process Tort claim presented to appropriate Federal agency within 2 years after claim arises (28 U.S.C. §2401(b)) No duplication of insurance coverage: U.S. pays Duplication of coverage and insurance company refuses Duplicative coverage and insurance company accepts its payment responsibility: company pays up to |