Form Cg Npfc-Ca1 - Optional Osltf Claim Form - Department Of Homeland Security Page 4
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48.
Indicate if claimant is pursuing payment from an insurance carrier for costs that are
included in the claim. If yes, provide all information that will enable us to contact the in-
surer and identify the claimant’s policy.
9.
Provide detailed information, evidence, and documentation that describes the extent of the
damage(s) claimed. Attach copies, if necessary, of all pertinent information.
10.
Provide any information, evidence, and documentation that will help describe how the oil
spill, or threat of oil spill, caused the removal costs and/or damage(s) claimed.
11.
Provide any information, evidence, and documentation that describe the actions of the
claimant or any other person on the claimant’s behalf to reduce or avoid the damage(s)
claimed.
12.
Provide the name, address and telephone number (if known) of any witness to the dam-
age(s) claimed. On a separate page provide a summary of each witness's knowledge of the
damage(s) claimed or the incident causing or suspected of causing the damage(s) claimed.
13.
If you provide additional documents, please list them here or on a separate piece of paper.
14.
If the claimant is an individual, that person must sign the claim. If the claimant is a
corporation, an officer of the company must sign the claim. All signatures must be in ink
to be valid.
15.
If the claim is presented by a legal representative, that legal representative must also sign
the claim. Provide the complete address and phone number of that legal representative.
Submit your claim, with any necessary information, evidence, and documentation to:
ATTN: CLAIMS ADJUDICATION
NATIONAL POLLUTION FUNDS CENTER
US COAST GUARD STOP 7100
4200 WILSON BLVD STE 1000
ARLINGTON VA 20598-7100
Claims for Natural Resource Damages or for Loss of Subsistence Use of Natural Re-
sources may be addressed to “
ATTN: NATIONAL RESOURCE DAMAGES CLAIMS
”.
DIVISION
We recommend that you keep the Privacy Act Statement and a copy of the claim for your files.
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