Claim For Damage Or Injury (Page 2 of 4) in pdf

Claim For Damage Or Injury Page 2

INSTRUCTIONS

Claims for property damage, loss or destruction, or for personal injury, must be

signed by the owner of the property or by the injured person, or by a parent or

guardian, in the case of a minor. If that person cannot sign because of death,

disability, or other reasons acceptable to the State of Hawaii, then a duly

authorized agent or other legal representative may file a claim and provide the

evidence satisfactory to the State of their authority to act.

You must state a dollar amount on page 2, Line 12 of the 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:

(a) For damage to property that has been or can be economically repaired,

submission of a photograph of the damaged property and two itemized

signed statements or estimates by reliable and independent parties. If

payment has been made, an itemized statement or receipt showing the

actual payment. Proof of ownership may also be required.

(b) For damages to a motor vehicle, copies of the current registration and

no-fault card will be required in addition to (a).

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 value of the claim.

(d) 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, hospital/clinic, copies of

medical bills and/or verification of other related expenses.

Form RMTC (9/97) Part 2 of 4

Claim For Damage Or Injury Page 2