Standard Form 95 (Rev. 2/2007), Claim for Damage, Injury, or Death Instructions

Please provide the time of the accident.

Please provide the month and year of the accident.

Please provide the day of the accident.

Check this box if you carry accident insurance.

Check this box if you do not carry accident insurance.

Provide the name and address of the accident insurance company (including Number, Street, City, State, and Zip Code) and the policy number.

Enter the amount of the claim for property damage.

Enter the amount of the claim for personal injury.

Enter the amount of the claim for wrongful death.

Enter the total amount of the claim.

Provide a detailed account of the known facts and circumstances related to the damage, injury, or death, including identification of persons and property involved, the place of occurrence, and the cause.

Check this box if you have filed a claim with your insurance carrier in this instance.

Check this box if you have not filed a claim with your insurance carrier in this instance.

Please provide details about the action your insurer has taken or proposed to take regarding your claim.

Please provide details regarding the claim filed with your insurance carrier, including information about full coverage or deductible.

Please enter the deductible amount.

Enter the full name and address of the claimant, including street number, street, city, state, and zip code, and include their personal representative if applicable.

Enter the date of birth.

Provide the name of the appropriate Federal Agency to which this claim is being submitted.

Enter the name of the first witness.

Enter the full address of the first witness, including street number, street name, city, state, and zip code.

Provide the claimant's current marital status.

State the nature and extent of each injury or cause of death that forms the basis of the claim; if other than the claimant, state the name of the injured person or decedent.

Enter the full name and complete address of the property owner, including number, street, city, state, and zip code, if different from the claimant.

Provide a brief description of the damaged property, the nature and extent of the damage, and the location where the property can be inspected.

Check this box if you carry public liability and property damage insurance.

Check this box if you do not carry public liability and property damage insurance.

Enter the name and full address, including number, street, city, state, and zip code, of the public liability and property damage insurance carrier.

Provide the full address of the second witness, including street number, street name, city, state, and zip code.

Provide the full name of the second witness.

Enter the date the form was signed.

Enter the phone number of the person signing this form.

Enter the street number, street name, city, state, and zip code for the third witness.

Enter the full name of the third witness.

Check this box if the claimant's type of employment is military.

Check this box if the claimant's type of employment is civilian.