Revised: August 21,2009 West Virginia Court of Claims Telephone (304) 347-4851 Instructions for Road Hazard or Damage to Real Estate 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 required by 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, telephone number, and e-mail address. 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 must be signed by claimant(s). DISTRIBUTION OF COPIES: 1. Submit white copy of claim form to this office and keep yellow copy for your records. NOT COMPLYING WITH THESE INSTRUCTIONS WILL DELAY THE PROCESSING OF YOUR CLAIM. American LegalNet, Inc. www.FormsWorkFlow.com Rev. 07/01/09 FILED WITH COURT OF CLAIMS ON ________________________________________ COURT USE ONLY Please read instructions thoroughly before completing this form. West Virginia Court of Claims 1900 Kanawha Blvd., E., Room W-334 Charleston, WV 25305-0610 (304) 347-4851 or (877) 562-6878 (toll free) www.legis.state.wv.us/joint/court/main.cfm E-mail: court.of.claims@wvlegislature.gov COURT USE ONLY _______________________________ CC- _ _ _ _ _ _ _ _ Suggested Form of Notice of Claim This claim form and any accompanying exhibits, including photographs, are requested to be submitted via e-mail, if possible. (court.of.claims@wvlegislature.gov) Please type or print. Failure to complete this form properly will delay processing of the claim. Mr. Ms. Dr. G G G _________________________________________ Claimant 1 ______________________________________________ VS. _____________________________ __________________________________ Claimant 2 (if applicable) Respondent State Agency Dollar Amount Claimed: Attorney Information (If attorney represents you in this claim) Claimant(s) Information _____________________________ _________________________________ Name Name ____________________________________________ E-mail ____________________________________________ E-mail _____________________________ _________________________________ Street Street _____________________________ _________________________________ City City _____________________________ _________________________________ County County _____________________________ _________________________________ State State Zip Zip _______________ _____________ _________________________________ Telephone Number Telephone Number FAX number Please note that the Court will conduct all correspondence through e-mail if one is provided. VEHICLE CLAIM: Date of accident_____________________ Time of accident_________________9 9 Place of accident (if applicable) ________________________________________________________ Street /Route number Nearest City/Town County Landmark at Scene, if any_____________________________________________________________ Year______ Make ____________ Model __________ Owner_________________________________ (continued on page 2) American LegalNet, Inc. www.FormsWorkFlow.com Notice of Claim Page 2 VEHICLE CLAIM (continued): IMPORTANT Please provide a copy of your declarations page from your insurance agent showing your deductible amount in effect on the date of the accident. If an award is made, you are limited in recovery in this Court to the amount of your collision deductible. Failure to include proper declarations page will delay processing of your claim. PROPERTY CLAIMS (such as drainage or slip claims): Name of property owner(s)_________________________________________________________ State facts of the claim clearly (use additional sheets if necessary): ___________________________________________________ Print or type name ______________________________________________________Signature of claimant(s) or designated attorney required ___________________________________________________ Date Upon the filing of this claim, you will receive an acknowledgment assigning a claim number (example: CC-00-####). Please refer to the assigned claim number in all correspondence with this office. §14-2-26: "A person who knowingly and wilfully presents or attempts to present a false or fraudulent claim, or a state officer or employee who knowingly and wilfully participates or assists in the preparation or presentation of a false or fraudulent claim, shall be guilty of a misdemeanor..." American LegalNet, Inc. www.FormsWorkFlow.com