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Home My Public Portal Aboutr 06:274 ~t5aluti(1u af t~t IßarauB~ af (Ill{ ttrd, ~ ~ JJ ~ No #06-274 D te of Adoption Oc.tober 2006 ADOPTING A TORT CLAIM QUES TONNAIRE 26. \ WHEREAS, the Borough of Carteret is a public entity purs ant to the New Jersey Tort Claims Act, NJ.S.A. 59:8-1 ~ §ffi ("Act"), and a membe of the Middlesex County Muoicipal Joint Insurance Fuod ("Fuod"), which was create pursuaot to the provisioos ofN.J.S.A. 40A:10-36 ~~aod WHEREAS, pursuant to the Act, NJ.S.A. 59:8-6, a pub ic entity may by rule or regulatioo adopt forms specifying information to be contain d in claims fíled against it under the Act; aod WHEREAS, the claims admioistrator for the Fund has d vised a standard form of questionnaire, medical authorization and employment verifie ion ("Tort Questionnaire") for requesting specific iofonnation from claimants ag 'nst the Fund's member municipalities and has proposed that it be adopted by the Fu d's member municipalities; and WHEREAS, the Mayor and Council of the Borough of arteret have reviewed the proposed Tort Questionnaire, a copy of which is attached h reto, and have determined that it is suitable for the purpose of soliciting necessary i formation from claimants pursuant to the Act; and WHEREAS, the Mayor aod Council of the Borough of Cart ret has determined that it is in the best interest to adopt the standardized form prop sed by the Fund's claims administrator in order to facilitate and expedite the proeessio of claims, NOW, THEREFORE, BE IT RESOLVED AS FOLLOW 1. The Mayor and Council of the Borough 0 Carteret hereby adopts the Tort QuestiOlmaire in the form attached he eta. 2. The Clerk shall immediately forward a c py of this resolution to the Executive Director of the Fund. Adopted this 26' day of October, 2006 and certified as true copy of the original on Octo er 27, 2006. KATHLEEN M BARNEY, RMC/CMC Municipal Clerk RECORD OF COUNCIL VOTE COUNCILMAN YES NO NV A.B. COUNCILMA YES NO NV A.B. x x X X . Indicate Vo¡e AS - Absem NV - NOI Voting: XOR - Indicat s Vote 10 Overrule Veto --.."'. .."¡;;IUt-ll~."ILõit:: Adopred at a meeting of the Municipal Council NOTIC FORWARD TO: (fill in name of entity) 1) CLAIMANT: Last First Middle Street Address City State Zip Code 2) IF NOTICE AND CORRESPONDENCE IN CO TO A PERSON OTHER THAN CLAIMANT, Last First Middle Street Address City State Zip Code 3) A) THE OCCURRENCE OR ACCIDENT WH Date B) DESCRJBE THE LOCATION OR PLACE Municipality E OF CLAIM Area Code/Phonl # Additional Addn ss D/O/B SS# NNECTION WI ;H THIS CLAIM ARE TO B PLEASE COMPL [TE ITEM #2: Area Codc/Phon # Additional Addr ss D/O/B SS# ICH GAVE RISE TO THIS CLAIM: Time OF THE ACCID r.NT OR OCCURRENCE: Exact Location 1 E SENT C. DESCRIBE HOW THE ACCIDENT OR OCCURRENCE HAPPENED. 1- A DIAGRAM WILL ASSIST YOUR EXPLANATION, PLEASE USE THE REVERSE SIDE OF THIS FORM: D. STATE THE NAME AND ADDRESS OF THE MUNICIPALITY OR AG -NCY THA T YOU CLAIM CAUSED YO DAMAGE: E. STATE THE NAMES OF MUNICIPALITY'S EMPLOYEES WHOM YO I, CLAIM WERE AT FAULT, INCLUDIN ANY INFORMATION THAT WILL ASSIST IN IDENTIFYING THEM: . F. STATE IN DETAIL EACH AND EVERY NEGLIGENT OR WRONGFUL ACT OF THE MUNICIPALITY EMPLOYEES WHICH CAUSED YOUR DAMAGE: . G. STATE THE NAME AND ADDRESS OF ALL WITNESSES TO THE A I-ClDENT OR OCCURRENCE: 2 UR G H. IF VEHICLE ACCIDENT, STATE THE NAMES, ADDRESS, AGE AND RELATIONSHIP TO INSURED OF AL PASSENGERS IN YOUR VEHICLE: I. STATE THE NAMES OF ALL POLICE OFFICERS AND POLICE DEPA TMENTS WHO INVESTIGATED THE ACCIDENT: 4) A. CLAIM FOR DAMAGES (check appropriate box): o BODILY INJURY o PROPERTY DAMAGE [ OTHER EXPLAIN B. 1. IF YOU CLAIM INJURY, DESCRIBE YOUR INJURIES RESULTlN G FROM THIS ACCIDENT OR OCCURRENCE: 3 L 2. DO YOU CLAIM PERMANENT DISABILITY RESUL TlNG FROM "HIS INJURY? DYES D NO IF YES, DESCRIBE THE INJURIES BELIEVED TO BE PERMANEN 3. FOR EACH HOSPITAL, DOCTOR, OR OTHER PRACTlTlIONER RENDERING TREATMENT, EXAMINATION OR DIAGNOSTIC SERVICE, STATE: NAME & ADDRESS OF HOSPITAL, DOCTOR, OR OTHER FACILITY DATES OF TREATMENT AMOUN"T OF CHARGE TO DATE AMOUNT PAID OR PAYABLE BY OTHER INSURANCE A) B) C) D) 4. IF YOU CLAIM LOSS OF WAGES OR INCOME AS A RESULT ( F THE INJURY, STATE: Address Name of Employer Date Em toyed at this Job Your Occupation Dates of <l.bsences from Work - Rate of Pay 4 ---.-- NOTE: IF YOUR CLAIMED LOSS OF INCOME ARISES FROM SELF-EMPL DYMENT OR OTHER THAN WAGE, AITACH A CALCULATION ON THE BASIS OF YOUR CALCULATION OF LOSS INCOME. 5. SET FORTH ANY AND ALL OTHER LOSSES OR DAMAGES Cl AIMED BY YOU: C. IF YOU CLAIM PROPERTY DAMAGE; 1. DESCRIBE THE PROPERTY DAMAGED, IF VEHICLE, INCLUD f- MAKE, MODEL, YEAR, COLOR, VEHICLE IDENTIFICATION NUMBER, LICENSE PLATE NUMBER, STATE AND PARTS OF VEHICLE DAMAGED: 2. THE PRESENT LOCATION AND TIME THE PROPERTY CAN B ~ INSPECTED: 3. DATE PROPERTY WAS ACQUIRED: 4. COST OF PROPERTY: 5. VALUE OF PROPERTY AT THE TIME OF ACCIDENT: 6. DESCRIPTION OF DAMAGE: 7. HAS THE DAMAGE BEEN REPAIRED? DYES DNo 5 IF YES, BY WHOM, AND COST OF REPAIRS: 8. ATTACH EACH ESTIMATE OF REPAIR COST TO THIS FORA. 9. SET FORTH IN DETAIL THE LOSS CLAIM BY YOU FOR PRO ÞERTY DAMAGE; D. SET FORTH IN DETAIL ALL OTHER ITEMS OF LOSS OR DAMAG ES CLAIMED BY YOU AND THE METHOD BY WHICH YOU MADE THE CALCULATIONS: 5) THE AMOUNT OF THE CLAIM: 6) HA VE YOU MADE A CLAIM AGAINST ANYONE ELSE FOR ANY OF frHE LOSSES OR EXPENSES OR EXPENSES CLAIMED IN THIS NOTICE? DYES DNO IF YES, SET FORTH THE NAMES AND ADDRESSES OF ALL PERSOt S AND THE INSURANCE COMPANIES AGAINST WHOM YOU HAVE MADE SUCH CLAIMS: 6 7) ARE ANY OF THE LOSSES OR EXPENSES CLAIMED HEREIN COVEl ED BY ANY POLICY OF INSURANCE? DYES 0 NO FOR EACH SUCH POLICY, STATE THE NAME AND ADDRESS OF TH~ INSURANCE COMPANY, POLICY NUMBER AND BENEFITS PAID OR PAYABLE: 8) HAVE YOU RECEIVED OR AGREED TO RECEIVE ANY MONEY FRO~ ANYONE FOR DAMAGES CLAIMED HEREIN? DYES 0 NO IF YES, SET FORTH THE DETAILS OF SUCH AGREEMENT: 9) THE FOLLOWING ITEMS MUST BE SUBMITTED WITH THIS NOTICE: 1. COPIES OF ITEMIZED BILLS FOR EACH MEDICAL EXPENSE AND OTHER LOSSES AND EXPENSES CLAIMED. 2. FULL COPIES OF ALL APPRAISALS AND ESTIMATES OF PRþPERTY DAMAGE CLAIMED BY YOU. 3. COPIES OF ALL WRITTEN REPORTS OF ALL EXPERT WITi'ESSES AND TREATING PHYSICIANS. 4. A LETTER FROM YOUR EMPLOYER VERIFYING YOUR LOS WAGES. IF SELF EMPLOYED, A STATEMENT SHOWING CALCULATIONS OF YOUR CLAIM LOST INCOME. 7 I HEREBY CERTIFY THAT THE FOREGOING STATEMENTS MADE BY M ARE TRUE, THAT THE ATIACHED STATEMENTS, BillS, REPORTS AND DOCUMENTS ARE THE ONLY ON S KNOWN TO ME TO BE IN EXISTENCE AT THIS TIME. I AM AWARE THAT IF ANY STATEMENT M DE HEREIN IS WillFUllY FALSE OR FRAUDULENT, I AM SUBJECT TO PUNISHMENT AS PROVIDED BY lA . DATED: Claimant or person filing on behalf of claimant Print name as sig ed above 8 AUTHORIZATION FOR MEDICAL REPORTS & RECORDS TO WHOM IT MAY CONCERN: I HEREBY AUTHORIZE ANY AND ALL DOCTORS, HOSPITALS 0 OTHER MEDICAL SERVICE FACILITIES TO RELEASE TO MIDDLESEX COUNTY MUNICIPAL JOINT I SURANCE FUND CLAIMS DEPARTMENT OR ITS REPRESENTATIVES ANY AND ALL RECORDS, RE ORTS AND OTHER INFORMATION CONCERNING THE TREAMENT OF THE CLAIMANT NAMED HEREIN. P OTOSTATTED COPIES OF THE AUTHORIZATION CARRY THE SAME AUTHORITY OF ORIGINAL. DATED: THIS MUST BE SIGNED BY THE CLAIMANT OR PARENTS OF THE CLAI NT WHO ARE MINORS. Print nam as signed above 9 AUTHORIZATION FOR INFORMATION ON MPLOYMENT TO WHOM IT MAY CONCERN: I HEREBY AUTHORIZE TO RELEASE ANY AND ALL MEDICAL INFORMATION CONCERNING MY EMPLOYME T, PAST OR PRESENT, INCLUDING RATE OF PAY, DUTIES PERFORMED, DATES OF ABSENCES AND REAS NS THEREFOR. PHOTOSTATTED COPIES OF THIS AUTHORIZATION CARRY THE SAME AUTHORITY AS HE ORIGINAL. DATED: ignature Print na e as signed above 10