Claim For Damage Or Injury printable pdf download

Claim For Damage Or Injury

IMPORTANT INFORMATION FOR FILING

A CLAIM FOR DAMAGE OR INJURY

Attached is the Claim for Damage or Injury form to file a tort claim incident

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 stated on

this form, as it will be used in resolving your claim. You may use additional

pages if necessary.

Please be advised that the State Tort Liability Act 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, repairs

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 before that 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 within ten (10) days of the

submission of your claim, contact the Risk Management Staff at 586-0547.

Form RMTC (9/97) P

art 1 of 4

Claim For Damage Or Injury