Tort Claim Form PLEASE CHECK THE FOLLOWING TO MAKE SURE ALL PERTINENT INFORMATION IS GIVEN BEFORE SUBMITTING YOUR CLAIM.

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1 Tort Claim Form If you have suffered an injury or damage to your property that you believe is the result of the negligence or actions of Rowan University or of individual(s) acting in the capacity of employee(s) of Rowan University, complete the Tort Claims Form following the instructions provided and send the form to New Jersey's Bureau of Risk Management at the address provided on the form. If you have any questions relating to this process, please contact: Robert D'Augustine, M.A., M.B.A., J.D. Director of Contract Administration and Risk Management Rowan University 201 Mullica Hill Rd. Glassboro, NJ voice: (856) fax: (856) PLEASE CHECK THE FOLLOWING TO MAKE SURE ALL PERTINENT INFORMATION IS GIVEN BEFORE SUBMITTING YOUR CLAIM. 1. A copy of the face sheet of your automobile insurance policy is enclosed. 2. A rough diagram showing the location of the alleged road defect in relation to a known fixed object is enclosed. 3. The correct time and date of your accident is supplied. 4. Submit information regarding motor or auto club insurance for towing and labor benefits, if available and also if applicable. 5. A copy of all estimates or bills regarding this incident is enclosed. 6. Describe the speed of the vehicle when it struck the alleged road defect, if applicable. 7. Describe the weather conditions at the time of the incident. 8. If tire(s) was damaged: Advise if there was a tire warranty reimbursement for road defects available. Describe the percentage of wear on the damaged tire (or tires). 9. Were the police at the scene or were they notified after the accident? 10. If exhaust system was damaged: Was the exhaust system original equipment on the car? If not, when was the last replacement made before the incident? 11. Advise the year, make, model number, license plate number and identity of the owner of the vehicle involved. 12. Submit the Driver s License number of the operator of the vehicle.

2 FOR OFFICE USE ONLY: CLAIM FOR DAMAGES AGAINST STATE OF NEW JERSEY Forward to: Bureau of Risk Management Tort & Contract Unit P.O. Box 620 One West State Street Trenton, New Jersey Claimant: Last Name, First Middle Date of Birth Street Address Mailing address if other than Street address City State Zip Code Social Security Number If notices and correspondence in connection with this claim are to be sent to a person other than claimant, complete Item #2. 2. Name Mailing Address City State Zip Code Relationship to claimant: Attorney at Law [ ] or Explain Relationship The occurrence or accident which gave rise to this claim: 3a. Date Time b. Describe the location or place of the accident or occurrence. Municipality Exact location of the occurrence c. Describe how the accident or occurrence happened: If a diagram will assist your explanation, please use the reverse side of this form.

3 d. State the name and address of the State agency or agencies that you claim caused your damage. e. State the names of State employees whom you claim were at fault, including any information that will assist in identifying and locating them. f. State the negligence or wrongful acts of the State agency and State employees which caused your damages. g. State the name and address of all witnesses to the accident or occurrence. h. State the names of all police officers and police departments who investigated the accident.

4 4a. Claim for Damages (check appropriate block) [ ] Personal Injury [ ] Property Damages [ ] Other Explain in detail b. If you claim personal injury: (1) Describe your injuries resulting from this accident or occurrence (2) Do you claim permanent disability resulting from this injury: [ ] Yes [ ] No If yes, describe the injuries believed to be permanent. (3) For each hospital, doctor or other practitioner rendering treatment, examination or diagnostic services, state: Name of hospital, doctor or other facility Address Dates if treatment or service Amount of charges to date Amount paid or payable by other sources such as insurance. (4) If you claim loss of wages or income as a result of the injury, state: Name of employer Your occupation Rate of pay Total lost wages to date Address of employer Date you became employed Dates of absence from work If still out, expected date of return

5 NOTE: If your claimed loss of income arises from self-employment or other than wages, attach calculation showing the basis of your calculation of lost income. I hereby certify that the foregoing statements made by me are true, that the attached statements, bills, reports and documents are the only ones known to me to be in existence at this time. I am aware that if any statement made herein is willfully false or fraudulent, that I am subject to punishment provided by law. Dated: Claimant or person filing claim on behalf of claimant. To Whom It May Concern: I hereby authorize any and all doctors, hospitals or other medical service facilities to release to the Sate of New Jersey any and all records, reports and other information concerning the treatment of the claimant named herein. Dated: (Signature) (This must be signed by the claimant or the parents of claimants who are minors)

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