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

Check this box if you do carry accident insurance (and then provide the name and address of the insurance company and the policy number as requested).

Check this box if you do not carry accident insurance.

Enter the full name of your accident insurance company, its complete mailing address (number, street, city, state, and ZIP code) and the policy number. Fill only if 'Question 15: Do you carry accident insurance? - Yes' Fill only if Do you carry accident Insurance? is 'Yes'.

Enter the dollar amount you are claiming for property damage resulting from the incident.

Enter the dollar amount you are claiming for personal injury damages (for example, medical expenses and related losses) resulting from the incident.

Enter the dollar amount you are claiming for wrongful death damages related to the incident.

Enter the total dollar amount of the claim, equal to the sum of all amounts claimed in 12a–12c. Fill only if '12a - Property Damage', '12b - Personal Injury', '12c - Wrongful Death' is filled (any).

Provide a detailed narrative of the facts and circumstances of the damage, injury, or death, including who and what was involved, where and when it occurred, the cause, and any other relevant information (use additional pages if needed).

Check this box if you have filed a claim with your insurance carrier in this instance (i.e., a claim has been submitted to your insurer regarding this loss).

Check this box if you have not filed a claim with your insurance carrier in this instance (i.e., no claim has been submitted to your insurer regarding this loss).

Explain whether you have filed a claim with your insurance carrier for this incident and state whether the claim is for full coverage or a deductible, including any relevant claim reference numbers or brief details. Fill only if 'Question 16 — Yes' Fill only if Have you filed a claim with your insurance carrier in this instance, and if so, is it full coverage or deductible? is 'Yes'.

Enter the deductible amount associated with the claim if the claim is for a deductible rather than full coverage. Fill only if '16. Insurance claim details' Fill only if Have you filed a claim with your insurance carrier in this instance, and if so, is it full coverage or deductible? indicates 'deductible'.

Enter the claimant's full name and mailing address (number, street, city, state and ZIP code); if applicable, include the claimant's personal representative.

Check this box if the claimant's type of employment at the time of the incident was military.

Check this box if the claimant's type of employment at the time of the incident was civilian.

Enter the claimant's date of birth.

Enter the claimant's marital status (for example: Single, Married, Divorced, Widowed).

Provide the time of day when the accident occurred and indicate whether it was A.M. or P.M.

Enter the day of the week on which the accident occurred (for example: Monday).

Enter the date on which the accident occurred.

Enter the date on which the claimant or person signing the form signed this document.

Enter the telephone number (including area code) of the person signing the claim form.

Describe what your insurance company has done or proposed to do regarding the filed claim, including actions taken, decisions made, communications, proposed settlements, denials, investigations, assigned claim number, dates, and any next steps. Fill only if 'Question 16 — Yes' Fill only if Have you filed a claim with your insurance carrier in this instance, and if so, is it full coverage or deductible? is 'Yes'.

Describe the nature and extent of each injury or cause of death that forms the basis of the claim, including the name of the injured person or decedent if different from the claimant and any relevant details of how and where the injury or death occurred. Fill only if '12b - Personal Injury', '12c - Wrongful Death' is filled (any).

Enter the full name and complete mailing address of the property owner if different from the claimant, including number, street, city, state, and ZIP code. Fill only if '12a - Property Damage' is filled.

Briefly describe the property, the nature and extent of the damage, and provide the exact location where the damaged property can be inspected. Fill only if '12a - Property Damage' is filled.

Check this box if you do carry public liability and property damage insurance and will provide the insurer's name and address.

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

Enter the full name and mailing address (number, street, city, state, and ZIP code) of your public liability and property damage insurance carrier; include any relevant policy or account identifier if space permits. Fill only if '19. Public liability and property damage insurance - Yes' Fill only if Do you carry public liability and property damage insurance? is 'Yes'.

Enter the full name (and optionally department/division) of the federal agency where this claim is being submitted; include any identifying office or unit if applicable.

Enter the full name of the first witness (first and last name, and middle initial if applicable).

Enter the complete mailing address for the first witness, including number, street, city, state, and ZIP code. Fill only if 'Witness 1 - Name' is filled.

Enter the second witness's complete mailing address including street number and name, city, state, and ZIP code. Fill only if 'Witness 2 Name' is filled.

Enter the full name of the second witness (first and last name, and middle initial if desired) who observed the incident.

Enter the witness's full mailing address including number and street, city, state, and ZIP code. Fill only if 'Witness 3 Name' is filled.

Enter the witness's full name (first name, middle initial if any, and last name).