WEB Form CC100 (1/98) West Virginia Court of Claims 1900 Kanawha Blvd., E., Room W-334 Charleston, WV 25305-0610 (304) 347-4851 Suggested Form of Notice of Claim (This claim form and any accompanying exhibits are required to be submitted in TRIPLICATE. This form can be filled in on-line and then printed out in triplicate and then signed.) _____________________________________ _____________________________________ Claimant 1 _____________________________________ VS. _____________________________________ Respondent State Agency (use both lines if needed) Claimant 2 (if applicable) Amount Claimed: $_____________________ Was the respondent State agency informed of the claim? u YES u NO What action, if any, was taken by the respondent agency?______________________________ ____________________________________________________________________________ Attorney Information (if applicable) Claimant(s) Information _____________________________________ _____________________________________ Name Name _____________________________________ _____________________________________ Street Street _____________________________________ _____________________________________ City City _____________________________________ _____________________________________ County County _____________________________________ _____________________________________ State State Zip Zip _____________________________________ _____________________________________ Telephone Number Telephone Number Place of accident (if applicable) : _________________________________________________ (Nearest city/town, street/route no., etc.) __________________________________________________________________________________________________________________________________ Date of accident: _____________________________________________________________ Did insurance cover all or any part of the claim? u YES u NO Amount of your insurance deductible, if any: $____________________________ continued on page 2 American LegalNet, Inc. www.USCourtForms.com Notice of Claim Page 2 State facts of the claim clearly: _____________________________________ Print or Type Name _____________________________________ Signature of Claimant(s) or Designated Attorney Required _____________________________________ Date of Signature Upon the filing of this claim, you will be notified of the date of the hearing, at which time you will be required to present evidence and prove your claim. §14-2-26:”A person who knowingly and willfully presents or attempts to present a false or fraudulent claim, or a state officer or employee who knowingly and willfully participates or assists in the preparation or presentation of a false or fradulent claim, shall be guilty of a misdemeanor...” American LegalNet, Inc. www.USCourtForms.com WEB claim Form Instructions West Virginia Court of Claims Telephone (304) 347-4851 Instructions For Filing a Claim CLAIMANT: Name of the titled owner(s) of the vehicle and/or name of the injured party, if any, or in case of real estate, name of property owner(s). RESPONDENT STATE AGENCY: This is usually the Division of Highways (DOH). AMOUNT CLAIMED: Actual payment for repairs, if made, or an estimate, may constitute the amount of the damages. If a claimant has insurance which will cover the damages to the vehicle, the claimant may recover only the deductible portion of the insurance. A copy of the insurance abstract is helpful to the Court. Subrogation claims by insurance companies are not considered by the Court. NAME AND ADDRESS OF ATTORNEY OR CLAIMANT: If claimant has an attorney, please complete these lines. If no attorney, claimant must complete the lines under Claimant Information, providing his/her name, address, and telephone number. FACTS OF YOUR CLAIM: Include the date, time, location, and circumstances of the incident in detail. Include the State Route number and any landmarks nearby, if known. State why the DOH, or other agency, should be liable for the damage. SIGNATURE: Claim form should be signed by claimant(s). Submit CLAIM FORM and all INVOICES in TRIPLICATE. CLAIMANT: Legal, corporate title of the vendor. RESPONDENT: Name of the State agency which incurred the expense. ATTORNEY AND/OR CLAIMANT ADDRESS: Name and address of the individual who is responsible for maintaining the information about the claim on behalf of the claimant company. If the claim is contested, the claimant corporation shall be represented by an attorney. AMOUNT OF CLAIM: Accurate total of the invoices. STATE THE FACTS OF THE CLAIM CONCISELY: Vendors should denote the fiscal year(s) for the invoices which constitute the claim. Also attach copies of the invoice(s) and add any explanation for failure of the agency to pay the invoice(s), if known. The amount claimed should be the sum of all invoices. Briefly state what the invoices for merchandise or services represent. SIGNATURE: Claim form should be signed by an individual with the legal capacity to bring a lawsuit on behalf of the corporation or partnership. WEBForm CC100 (1/98) American LegalNet, Inc. www.USCourtForms.com