Research Corporation of the University of Hawaiʻi

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STATE OF HAWAII
CLAIM FOR DAMAGE OR INJURY
YOUR CLAIM CANNOT BE PROCESSED UNLESS THIS FORM IS FULLY COMPLETED AND SIGNED. ATTACH ADDITIONAL PAPER IF NECESSARY.
1. FIRST NAME: ______________________ MIDDLE: _______________ LAST: __________________________
2. GENDER: MALE FEMALE
3. IF THE CLAIMANT IS A MINOR, PROVIDE THEIR BIRTH DATE: ___________________
4. PARENT OR LEGAL GUARDIAN NAME IF CLAIMANT IS A MINOR:
FIRST NAME: ___________________________ LAST: __________________________________
5. RESIDENCE ADDRESS: Street: _______________________________________________________________ City: __________________________ State: ______ Zip: __________
6. IF THIS IS AN INJURY CLAIM, IS THE CLAIMANT A MEDICARE/MEDICAID BENEFICIARY YES NO
7. PHONE (HOME/CELL): ___________________________ PHONE (WORK): ________________________
8. EMAIL: ____________________________________________________ 9. OCCUPATION: _____________________________________________
10. EMPLOYER: ______________________________________________
11. DATE INCIDENT OCCURRED: ____________________ TIME: ___________ AM PM
12. SPECIFIC LOCATION OF INCIDENT: (Identify street, cross street, lane of travel, direction of travel, city)
13. DESCRIBE WHAT OCCURRED IN DETAIL, PROVIDE ALL KNOWN FACTS AND IDENTIFY PEOPLE OR PROPERTY INVOLVED. ATTACH PHOTOGRAPHS, MAPS,DIAGRAMS, ETC. TO EXPLAIN THE INCIDENT.
14. EXPLAIN WHY YOU FEEL THE STATE OF HAWAII IS AT FAULT:
15. DESCRIBE THE SPECIFIC NATURE & EXTENT OF THE INJURY, PROPERTY DAMAGE OR LOSS:
Original to: DAGS/Risk Management Form RMTC-001 (08/16) P. 1 of 2
If
Original to: DAGS/Risk Management Form RMTC-001 (08/14) P. 1 of 2
16. IF AUTOMOBILES ARE INVOLVED, HAVE YOU ALREADY FILED A CLAIM WITH AN AUTO INSURANCE COMPANY REGARDING THIS INCIDENT? YES NO
IF “YES”, PROVIDE THE AUTO COMPANY’S NAME, THE POLICY NUMBER, THE CLAIM NUMBER, THE ADJUSTER NAME AND PHONE NUMBER:
17. WAS A POLICE REPORT COMPLETED? YES NO
IF YES, PROVIDE THE POLICE REPORT # __________________
18. WERE THERE ANY WITNESSES WHO SAW THE INCIDENT? YES NO IF YOU ANSWERED YES:
NAME: ___________________________________ PHONE: _______________________________
ADDRESS: _______________________________________________________________
EMAIL: _______________________________________________________________
19. DID YOU PREVIOUSLY REPORT THIS INCIDENT TO THE STATE? YES NO IF YOU ANSWERED YES:
DATECLAIMWASORIGINALLYREPORTED: _____________________
HOW WAS THE CLAIM REPORTED: __________________________________________________ NAME OF STATE EMPLOYEE REPORTED TO: __________________________________________ CONTACT INFO FOR THAT STATE EMPLOYEE: _________________________________________
20. AMOUNT OF THE CLAIM (SEE INSTRUCTIONS FOR VERIFICATION OF THE AMOUNT):
PROPERTY DAMAGE: $____________________ PERSONAL INJURY: $ ____________________
ATTACH A COPY OF ALL SUPPORTING DOCUMENTATION (INCLUDING A COPY OF THE POLICE REPORT). IF THIS IS A PROPERTY DAMAGE CLAIM, THE OWNER OF THE DAMAGED PROPERTY MUST SIGN THIS FORM. FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THAT PRESENTING A FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT IS A CRIME PUNISHABLE BY FINES OR IMPRISONMENT, OR BOTH.
I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
_______________________________ ____________________________ __________________ SIGNATURE FULL NAME DATE
______________________________________________________ _________________________________ MAILING ADDRESS (WITH CITY, STATE, ZIP CODE)
_______________________________________________________________________________________ EMAIL
Original to: DAGS/Risk Management Form RMTC-001 (08/16) P. 2 of 2
Form RMTC-001 (08/14) P. 2 of 2