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