Claim For Damage Or Injury (Page 3 of 4) in pdf

Claim For Damage Or Injury Page 3

CLAIM FOR DAMAGE OR INJURY

PRINT IN INK OR TYPE

Full name of claimant/victim (provide age if minor):

(Mr./Ms.)

___________________________________________________

Residence Address (include zip code):__________________________

_______________________________________________________________

Phone:

Res:

_________________

Bus:

________________________

Occupation: ___________________________________________________

Place of Employment: __________________________________________

_______________________________________________________________

Location of Incident/Address: _________________________________

_______________________________________________________________

Date of Incident: ____________

Day of Week: ____________

Time: __________________

Description of Incident:

(State, in detail, all known facts and

circumstances, identify person and property involved, and why

you believe the State of Hawaii is at fault.

If possible,

please enclose photographs, maps, diagrams, etc., to help us

understand the incident.)

_________________________________________________________________

orm RMTC (9/97)

Part 3 of 4

Claim For Damage Or Injury Page 3