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Notice of Tort Claim Form for Township of Howell, New Jersey, Slides of Public Policy

A Notice of Tort Claim form for filing claims against the Township of Howell in New Jersey. It includes instructions, definitions, and questions related to the claimant, claim, property damage, personal injury, and basis for the claim against the public entity or public employee. The form requires providing information about the claimant, the alleged injury or property damage, and any relevant parties or insurance policies.

What you will learn

  • What is the nature of the injury or property damage alleged?
  • What is the basis for the claim against the public entity or public employee?
  • What is the specific nature of the act or omission alleged to have caused the injury or property damage?
  • What public entities or public employees are alleged to have caused the injury or property damage?
  • What information must be provided about the claimant?

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2021/2022

Uploaded on 09/27/2022

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TOWNSHIP of HOWELL
4567 Route 9 North
(732)
938-4500
Post Office B
ox 580 FAX (732) 414-3232
Howell, New Jersey 07731-0580
website: www.twp.howell.nj.us
CLAIMANT INFORMATION
Name:
_____________________________
Telephone:
____________________
Address: _____________________________
Date of Birth:
____________________
_____________________________
_____________________________
Social Security#: __________________
ATTORNEY INFORMATION (If Applicable)
Name:
_____________________________
Telephone: ____________________
Address: _____________________________
Fax:
_______________________
_____________________________
_____________________________
File No.:_______________________
Send Notices to:
Claimant
Attorney
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Download Notice of Tort Claim Form for Township of Howell, New Jersey and more Slides Public Policy in PDF only on Docsity!

TOWNSHIP of HOWELL

4567 Route 9 North (732) 938- Post Office Box 580 FAX (732) 414- Howell, New Jersey 07731- website: www.twp.howell.nj.us CLAIMANT INFORMATION Name: _____________________________ Telephone: ____________________ Address: _____________________________ Date of Birth: ____________________


_____________________________ Social Security#: __________________ ATTORNEY INFORMATION (If Applicable) Name: _____________________________ Telephone: ____________________ Address: _____________________________ Fax: _______________________


_____________________________ 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 Township of Howell. 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: Allison Ciranni, Township Clerk Township of Howell Post Office Box 580 Howell, NJ 07731 NOTE CAREFULLY: Your claim will not be considered filed as required under the New Jersey Tort Claims Act until this completed form has been filed with the Township of Howell. 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.” It you are unable to answer any questions 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 Township. “ 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 Township of Howell along with any agent, official, or employee of the Township of Howell against whom a claim is asserted by the Claimant.

  1. Provide the Claimant’s complete version of the events that form the basis of the claim.
  2. 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.
  3. State the name of all police officers and police departments who investigated the accident.
  4. 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.
  5. 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.
  6. 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.
  1. If you or any other party or witness consumed any alcoholic beverages, drugs or medications within twelve 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.
  2. 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 payers. Specifically list any policies of insurance, including policy number and claim number, from which benefits have been paid to you or to any person of your behalf, including doctors, hospitals or any person repairing damage to property.
  3. 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 maps and of the persons who have present possession thereof. Attach copies of any photographs, sketches, charts or maps.
  4. 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; the date and place where said; and in whose presence, giving names and addresses of any persons having knowledge thereof.
  5. State the total amount of your claim and the basis on which you calculated the amount claimed as of the date of presentation.
  6. State the amount claimed as of the date of the claim; include the estimated amount of any prospective injury, damage, or loss and the basis for computation of the amount claimed.

i) Set forth, in detail, the loss claimed by you for property damage.




  1. Set forth, in detail, all other items of loss or damages claimed by you and the method by which you made the calculation.

  2. The amount of the total claim. ___________________________________________________________ PERSONAL INJURY CLAIMS
  3. 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.
  4. Describe in detail the nature, extent and duration of any and all injuries.
  5. Describe in detail any injury or condition claimed to be permanent.
  6. If confined to any hospital, state name and address of each and the dates of admissions and discharge. Include all hospital admissions prior to and subsequent to the alleged injury and give the reason for each admission.
  1. 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.
  2. If treated by doctors, including psychiatrist or psychologist, state (a) the name and present address of each doctor, (b) the dates and places where treatments were treatments are continuing, the schedule of continuing treatments. Provide true copies of all written reports rendered to you or about you by any doctor whom you propose to have testify on your behalf.
  3. 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 movement, 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.
  4. 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.
  5. If any treatments, operations, 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 operations 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 expenditure anticipated as a result of the treatment, operations or surgery, (h) further if it is your intention to undergo the treatments, operation or surgery, please give an approximate date.

Title 59 The Legislature recognizes the inherently unfair and inequitable results which occur in the strict application of the traditional doctrine of sovereign immunity. On the other hand the Legislature recognizes that while a private entrepreneur may readily be held liable for negligence within the chosen ambit of his activity, the area within which government has the power to act for the public good is almost without limit and therefore government should not have the duty to do everything that might be done. Consequently, it is hereby declared to be the public policy of this State that public entities shall only be liable for their negligence within the limitations of this act and in accordance with the fair and uniform principles established herein. All of the provisions of this act should be construed with a view to carry out the above legislative declaration. L.1972, c. 45, s. 59:1-2.

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. I am aware that if any statement made is willfully false, that I am subject to punishment provided by law. Signature of Claimant:___________________________ Date: __________________

To Whom It May Concern: I hereby authorize any and all doctors, hospitals or other medical service facility to release to the:


or its representatives, any and all records, reports and other information concerning the treatment of the claimant named herein. I, (YOUR NAME), hereby authorize the use and disclosure of my individually identifiable health information and other medical and insurance records. I understand that once disclosed, the information I authorize to be disclosed by said person/facility may be disclosed to others and will no longer be protected by state and federal regulations. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 42 U.S.C. 1320d and 45 C.F.R. 160-164. Signature of Claimant __________________________ Date: ___________________ (This form must be signed by claimant or the parents of the claimants who are minors.)