Notice Of Tort Claim Page 3

d. State the name and address of the Public Entity, or entities, that you claim caused

your damage.

State the names of the employees whom you claim were at fault, including any

information that will assist in identifying and locating them.

e. State, in detail, the negligence or wrongful acts of the Public Entity and public

employees which caused your damages.

f. State the name and address of all witnesses to the accident or occurrence.

g. State the names of all police officers and police departments who investigated the

accident.

4a.

Claim for Damages (Check appropriate block.)

( ) Personal Injury

( ) Property Damage

( ) Other – Explain in Detail _______________________________________

_________________________________________________________________________

b. If you claim personal injury:

(1) Describe your injuries resulting from this accident/occurrence.

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