Form Cg Npfc-Ca1 - Optional Osltf Claim Form - Department Of Homeland Security Page 2
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4Optional OSLTF Claim Form
CG NPFC-CA1
8. Has claimant submitted or planned to submit the loss to an insurer?
No
Yes
Please provide
the name, address, and phone number of your insurer, the policy number, and explain any compensation received:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
9. Description of the nature and extent of damages claimed (Attach additional information as necessary): __________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
10. Description of how the incident caused the damage: __________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
11. Description of actions taken by claimant/representative to avoid or minimize damages: ____________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
12. Witnesses:
Name: _____________________________________________ Tel. No.: __________________________________________
Address: _______________________________________________________________________________________________
______________________________________________________________________________________________
Name: _____________________________________________ Tel. No.: __________________________________________
Address: _______________________________________________________________________________________________
______________________________________________________________________________________________
13. List Documents or Attachments (Attach additional information as necessary):
a. ____________________________________________________________________________________________________
b. ____________________________________________________________________________________________________
c. ____________________________________________________________________________________________________
d. ____________________________________________________________________________________________________
e. ____________________________________________________________________________________________________
I, the undersigned, agree that upon acceptance of any compensation from the Fund, I will cooperate fully with the United States in any
claim or action by the United States to recover the compensation. The cooperation shall include, but is not limited to, immediately
reimbursing to the Fund any compensation received from any other source for the same costs and/or damages and, providing any
documentation, evidence, testimony, and other support, as may be necessary for the Fund to recover such compensation.
I, the undersigned, certify that, to the best of my knowledge and belief, the information contained in this claim represents all material
facts and is true. I understand that misrepresentation of facts is subject to prosecution under Federal law (including but not limited to 18
U.S.C. 287 & 1001 and 31 U.S.C. 3729).
14. _________________________________________________
15._______________________________________________
Claimant’s Signature
Date
Legal Representative
Date
Printed Name of Signer:
Title/Legal Capacity:
CG NPFC-CA1 (APR 03)
Page 2 of 2
Previous edition can be used
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