Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 Notice of Intent of Claim for Personal Injury IN THE COURT OF CLAIMS, STATE OF ILLINOIS To: Attorney General Lisa Madigan 100 W. Randolph St. Chicago, IL 60602 Illinois Court of Claims Secretary of State Jesse White Ex Officio Clerk of the Court 630 S. College St. Springfield, IL 62756 The undersigned hereby serves Notice of Claim for personal injuries upon the State of Illinois pursuant to the Illinois Revised Statutes, Chapter 37, Section 439.22-1. ________________________________________________________________________________________________________ Name of Person to whom Injuries Occurred ________________________________________________________________________________________________________ Name of Person Injured ________________________________________________________________________________________________________ Residence of Person Injured ________________________________________________________________________________________________________ Place of Accident ________________________________________________________________________________________________________ Statement of Accident ________________________________________________________________________________________________________ Date and Hour of Accident ________________________________________________________________________________________________________ Name and Address of Attending Physician ________________________________________________________________________________________________________ Name and Address of Treating Hospital Signed: ________________________________________________ Claimant’s Signature ________________________________________________ Street Address ________________________________________________ City State ________________________________________________ ZIP Telephone Number American LegalNet, Inc. www.USCourtForms.com Printed by authority of the State of Illinois - March 2005 - 500 - CC-86