Research Corporation of the University of Hawaiʻi

STATE OF HAWAII IMPORTANT INFORMATION FOR FILING A CLAIM FOR DAMAGE OR INJURY
Attached is the “Claim For Damage Or Injury” form to file a tort claim against the State of Hawaii.
In order for the State to conduct a meaningful investigation, the form must be completed in detail and in its entirety. All material facts should be clearly stated and you may use additional pages if necessary. All supporting documentation should be attached.
Please be advised that the State Tort Liability Act, HRS §662, makes the State responsible only when the State is negligent and when that negligence causes an injury or damage. The State is not automatically responsible for bills (medical, repair or other) because an incident occurs on its premises or as a result of its operations. It is your responsibility to fulfill your financial obligations.
You have two (2) years from the date of the incident to finalize your claim. If you are not satisfied with the outcome of your claim and decide to sue, a lawsuit must be filed within the two (2) year period, otherwise the statute of limitations will prevent your claim from being considered or settled.
Follow the attached instructions and submit your original claim form and one copy to:
State of Hawaii
Department of Accounting and General Services Risk Management
P.O. Box 119
Honolulu, Hawaii 96810-0119
Retain these pages for your future reference. If you have any questions, or if you do not receive an acknowledgement letter from the State within ten (10) days of the submission of your claim, contact the Risk Management staff at 808-586-0547.

INSTRUCTIONS
Claims for property damage, loss or destruction must be signed by the owner of the property, or by a parent or guardian in the case of a minor. Claims for personal injury must be signed by the injured person, or by a parent or guardian in the case of a minor. If that person cannot sign the form because of death, disability or other reasons acceptable to the State, then a duly authorized agent or other legal representative may file a claim and provide evidence satisfactory to the State of their authority to act on behalf of that person.
You must state a specific dollar amount on page 2, line 20, of the claim form. If your claim is accepted by the State, the dollar amount of your claim will need to be documented by independent verification and evidence. However, you are not required to submit this information at this time.
The following are examples of acceptable means of independent verification or documentation:
 For damage to property that has been or can be economically repaired, the submission of photographs of the damaged property and two itemized signed statements or estimates by reliable and independent parties. If payment has already been made, an itemized statement or receipt showing that the payment was actually received. Proof of ownership may also be required.
 For damages to a motor vehicle, copies of the vehicle registration and the insurance card in force on the applicable date of loss will also be required.
 For lost or destroyed property, or for damage to property which cannot be economically repaired, submission of statements itemizing each item, original cost of the item, date purchased, where purchased and the value of the item before and after the incident can be used in determining the actual cash value of the claim.
 For personal injury or death, medical information will be required. This may involve securing an authorization to release medical information, securing a report from a doctor or hospital/clinic, obtaining medical bills and/or other verification of related expenses.