State of Nevada Potential Liability Incident Report INSTRUCTIONS: State Agency should use this form to report potential liability claims against the State This 223Incident Report224 should be sent ASAP to: Claims Manager, Office of the Attorney General Interdepartmental Mail, or Via fax to 775-684-, or , Carson City, NV 897 If an individual wishes to make a formal claim against the State, the individual should contact the Office of the Attorney General at TEL: 775-684-1252 or 775-684-1263; FAX 775-684-. The Attorney General222s office will send the appropriate form to the injured/damaged party PLEASE NOTE: Do not use this form to report injuries of State employees. A Worker222s Compensation injury report must be filed in those instances. Please type or print clearly Name of Injured/Damaged Party: Mailing Address: Telephone #: Date of Incident: Time: Location where incident occurred (include street address): Department: Budget Account:Division: Contact Person: Title: Telephone #: TC-1 Claim form provided to injured/damaged party? Yes No Please provide a detailed description of what happened and attach all supporting documentation you may have. (Attach additional pages/photographs, if necessary): Form completed by: Date: TC-2 (Form revised ) Office of the Attorney General American LegalNet, Inc. www.FormsWorkFlow.com