Chapter 3 Investigation of Liability
|
|
|
- Sylvia Quinn
- 5 years ago
- Views:
Transcription
1 Chapter 3 Investigation of Liability 2015_GA_Personal Injury_Interiors.indd 61
2 3-000 After notifying the appropriate parties of your client s claim, you need to send requests for information concerning the liability of the defendant. You can obtain a number of documents through Open Records Act requests. Under Georgia law, governmental entities are required to provide copies of investigative documents to you pursuant to an Open Records Act request unless there is an exception that protects the documents from disclosure. You should send requests to obtain a copy of the accident/incident report and any investigative reports or records relevant to the claim. Below is a list of the forms in this chapter, as well as a brief summary of when to use them: Letter to Insurer Requesting Client s Recorded Statement -Use this form to request a copy of your client s statement from the defendant s insurer Letter Requesting Accident Report from Police -Use this form to request a motor-vehicle accident report Open Records Act Request to Police for Entire Investigative File -Use this form to request to obtain the complete investigative file from the police Open Records Act Request for 911 Tapes/CAD Report -Use this form to request 911 tapes for the incident Letter Requesting Certified Copy of Guilty Plea -Use this form to obtain a certified guilty plea of the defendant driver Letter to GBI Requesting Autopsy Report -Use this form to request an autopsy report Letter to GBI Requesting Toxicology Reports -Use this form to request a drug or alcohol screen Freedom of Information Act Request to Federal Governmental Entity -Use this form to request records from the federal government Freedom of Information Act Request to Federal Motor Carrier Safety Administration -Use this form to request records on an interstate trucking company Open Records Act Request to MARTA for Elevator/Escalator Incident 62 Library of Georgia Personal Injury Forms, 4th 2015_GA_Personal Injury_Interiors.indd 62
3 -Use this form to request records from MARTA for an elevator/escalator incident Open Records Act Request to Department of Human Resources -Use this form to request records about nursing homes or assisted-living facilities Open Records Act Request to Animal Control -Use this form to request records about a dog s history of violence Open Records Act Request to Police for Criminal History of Property -Use this form to request records when a person is assaulted at a complex Open Records Act Request to Internal Affairs/Police Department for Excessive Force -Use this form to request records after an excessive force incident Open Records Act Request to Department of Labor -Use this form to request records concerning an elevator or escalator Chapter 3 Checklist Library of Georgia Personal Injury Forms, 4th _GA_Personal Injury_Interiors.indd 63
4 3-001 LETTER TO INSURER REQUESTING CLIENT S RECORDED STATEMENT [DATE] [NAME OF INSURANCE COMPANY] [ADDRESS] Re: Claim No.: [INSURANCE CLAIM NUMBER] Insured: [DEFENDANT NAME] Date of Loss: [DATE OF LOSS] Our Client: [CLIENT NAME] Dear [NAME OF ADJUSTER OR INSURANCE COMPANY]: As you are aware, this firm has been retained to represent the interests of [CLIENT NAME] who suffered personal injuries as a result of an incident involving [DEFENDANT NAME]. In the event your company or anyone on your behalf has taken any statements, recorded, written or otherwise from [CLIENT NAME], please accept this letter as a formal request for copies of any such statements. If you have any questions, please do not hesitate to call. Sincerely, [ATTORNEY NAME] 64 Library of Georgia Personal Injury Forms, 4th 2015_GA_Personal Injury_Interiors.indd 64
5 3-002 LETTER REQUESTING ACCIDENT REPORT FROM POLICE [DATE] [NAME OF POLICE DEPARTMENT] [ADDRESS] RE: Georgia Open Records Act Request Date of Accident: [DATE OF COLLISION] Our Client: [CLIENT NAME] DOB: [DATE OF BIRTH] Dear Sir/Madame: This law firm represents [CLIENT NAME] in a claim arising from an automobile collision that occurred at [LOCATION] on [DATE]. Pursuant to O.C.G.A , the Georgia Open Records Act, we hereby request the following: the Georgia Motor Vehicle Accident Report from this collision. We have enclosed payment of $5.00 to cover the cost of the accident report. If you have any questions, please do not hesitate to call. Sincerely, [ATTORNEY NAME] Library of Georgia Personal Injury Forms, 4th _GA_Personal Injury_Interiors.indd 65
6 3-003 OPEN RECORDS ACT REQUEST TO POLICE FOR ENTIRE INVESTIGATIVE FILE [DATE] [NAME OF POLICE DEPARTMENT] [ADDRESS] RE: Georgia Open Records Act Request Date of Accident: [DATE OF COLLISION] Our Client: [CLIENT NAME] Accident Report No.: [ACCIDENT REPORT NUMBER] Dear Sir/Madame: This law firm represents [CLIENT NAME] in a claim arising from an automobile collision that occurred at [DESCRIPTION OF LOCATION] on [DATE]. A copy of the Georgia Motor Vehicle Accident Report is enclosed. Pursuant to O.C.G.A , the Georgia Open Records Act, we hereby request your entire investigative file including the following: a. 911 tapes; b. 911 CAD reports; c. photographs; d. witness statements; e. inspection reports; f. videotapes; g. drawings; h. scene diagrams; i. total station survey; j. audio recordings; k. test results; 66 Library of Georgia Personal Injury Forms, 4th 2015_GA_Personal Injury_Interiors.indd 66
7 l. computer data; m. witness information; n. any documents generated or obtained relating to this incident. As I am sure you are aware, O.C.G.A (f) requires individuals in control of public records to respond to requests for documents within three business days, or provide a written description of all available records and documents together with a timetable for their inspection and copying. The individual in control of such public record or records shall have a reasonable amount of time to determine whether or not the record or records requested are subject to access under this article and to permit inspection and copying. In no event shall this time exceed three business days. Where responsive records exist that are not available within three business days of the request, a written description of such records, together with a timetable for their inspection and copying, shall be provided within that period. O.C.G.A (f). We understand that the production may take longer, so please just let us know if there will be a substantial delay. We look forward to your response. Sincerely, [ATTORNEY NAME] Enclosure Library of Georgia Personal Injury Forms, 4th _GA_Personal Injury_Interiors.indd 67
8 3-004 OPEN RECORDS ACT REQUEST FOR 911 TAPES/CAD REPORT [DATE] 911 Call Center [COUNTY NAME] [ADDRESS] RE: Georgia Open Records Act Request Date of Accident: [DATE OF ACCIDENT] Our Client: [CLIENT NAME] Dear Sir/Madame: This law firm represents [CLIENT NAME] in a claim arising from an automobile collision that occurred at [DESCRIPTION OF LOCATION] on [DATE]. A copy of the Georgia Motor Vehicle Accident Report is enclosed. Pursuant to O.C.G.A , the Georgia Open Records Act, we hereby request the following: All audio tapes and/or transcripts in your possession of 911 calls made to your center on the date of the accident relating to the subject collision in the above-referenced matter. As I am sure you are aware, O.C.G.A (f) requires individuals in control of public records to respond to requests for documents within three business days, or provide a written description of all available records and documents together with a timetable for their inspection and copying. We understand that this may take longer, so please just let us know if there will be a substantial delay. The individual in control of such public record or records shall have a reasonable amount of time to determine whether or not the record or records requested are subject to access 68 Library of Georgia Personal Injury Forms, 4th 2015_GA_Personal Injury_Interiors.indd 68
9 under this article and to permit inspection and copying. In no event shall this time exceed three business days. Where responsive records exist that are not available within three business days of the request, a written description of such records, together with a timetable for their inspection and copying, shall be provided within that period. O.C.G.A (f). We look forward to your response. If we are responsible for any copying fees, we will be glad to reimburse you. Sincerely, [ATTORNEY NAME] Enclosure Library of Georgia Personal Injury Forms, 4th _GA_Personal Injury_Interiors.indd 69 3/27/15 7:44:10 PM
10 3-005 LETTER REQUESTING CERTIFIED COPY OF GUILTY PLEA [DATE] [NAME OF TRAFFIC COURT] [ADDRESS] Re: Georgia Open Records Act Request Defendant: [DEFENDANT NAME] Date of Accident: [DATE OF ACCIDENT] Dear Sir/Madame: This law firm represents [CLIENT NAME] in a claim arising from an automobile collision that occurred at [LOCATION] on [DATE]. A copy of the Georgia Motor Vehicle Accident Report is enclosed. Pursuant to O.C.G.A , the Georgia Open Records Act, we hereby request the following: a certified copy of the defendant s plea to any charges related to this incident. As I am sure you are aware, O.C.G.A (f) requires individuals in control of public records to respond to requests for documents within three business days, or provide a written description of all available records and documents together with a timetable for their inspection and copying. We understand that this may take longer, so please just let us know if there will be a substantial delay. The individual in control of such public record or records shall have a reasonable amount of time to determine whether or not the record or records requested are subject to access under this article and to permit inspection and copying. In no event shall this time exceed three business days. Where responsive records exist that are not available within three 70 Library of Georgia Personal Injury Forms, 4th 2015_GA_Personal Injury_Interiors.indd 70 3/27/15 7:44:10 PM
11 business days of the request, a written description of such records, together with a timetable for their inspection and copying, shall be provided within that period. O.C.G.A (f). We look forward to your response. If we are responsible for any copying fees, we will be glad to reimburse you. Sincerely, [ATTORNEY NAME] Enclosure Library of Georgia Personal Injury Forms, 4th _GA_Personal Injury_Interiors.indd 71 3/27/15 7:44:10 PM
12 3-006 LETTER TO GBI REQUESTING AUTOPSY REPORT [DATE] Open Records Unit Georgia Bureau of Investigation 3121 Panthersville Road Decatur, Georgia Re: Georgia Open Records Act Request Date of Accident: [DATE OF ACCIDENT] Decedent: [DECEDENT NAME] DOB: [DECEDENT S DATE OF BIRTH] Dear Sir/Madame: This law firm represents the family of [DECEDENT NAME] in a wrongful death claim arising from [DESCRIPTION OF INCIDENT] that occurred at [DESCRIPTION OF LOCATION] on [DATE] in which [DECEDENT NAME] was killed. A copy of the incident report is enclosed. Pursuant to O.C.G.A , the Georgia Open Records Act, we hereby request the following: The autopsy report for [DECEDENT NAME], including all related documents, reports, charts, photographs and other material documented by your office. As I am sure you are aware, O.C.G.A (f) requires individuals in control of public records to respond to requests for documents within three business days, or provide a written description of all available records and documents together with a timetable for their inspection and copying. However, we understand that this may take longer than the designated three days. Please just let us know if there will be a substantial delay. 72 Library of Georgia Personal Injury Forms, 4th 2015_GA_Personal Injury_Interiors.indd 72 3/27/15 7:44:10 PM
13 The individual in control of such public record or records shall have a reasonable amount of time to determine whether or not the record or records requested are subject to access under this article and to permit inspection and copying. In no event shall this time exceed three business days. Where responsive records exist that are not available within three business days of the request, a written description of such records, together with a timetable for their inspection and copying, shall be provided within that period. O.C.G.A (f). We look forward to your response. Sincerely, [ATTORNEY NAME] Library of Georgia Personal Injury Forms, 4th _GA_Personal Injury_Interiors.indd 73 3/27/15 7:44:10 PM
NEW YORK STATE BAR ASSOCIATION. LEGALEase. If You Have An Auto Accident
NEW YORK STATE BAR ASSOCIATION LEGALEase If You Have An Auto Accident If You Have An Auto Accident What should you do if you re involved in an automobile accident in New York? STOP! By law, you are required
Collision Reporting, Investigation, and Analysis
In this procedure, a collision is defined as any occurrence involving a motor vehicle driven by an employee on company business which results in death, injury, or property damage, unless the vehicle is
Administrative Policies and Procedures Page 2
Administrative Policies and Procedures Page 2 2.5.3 MINIMUM DRIVING STANDARDS Authorization to drive a Commission-owned, leased, or personal vehicle for Commission business will be granted only when an
NC General Statutes - Chapter 20 Article 10A 1
Article 10A. Transportation Network Companies. 20-280.1. Definitions. The following definitions apply in this Article: (1) Airport operator. Any person with police powers that owns or operates an airport.
BERGEN COUNTY MUNICIPAL JOINT INSURANCE FUND. Name: Telephone: Name: Telephone: Address: Fax: File No.:
BERGEN COUNTY MUNICIPAL JOINT INSURANCE FUND CLAIMANT INFORMATION Name: Telephone: Address: Date of Birth: ATTORNEY INFORMATION (If Applicable) Name: Telephone: Address: Fax: File No.: Send Notices to:
Dear Valued Customer:
Administered by Travel Insured International; Claims Department Dear Valued Customer: We are sorry that your travel plans were disrupted. We have attached the following checklist and claim forms that you
Creation of Kansas Transportation Network Company Services Act; House Sub. for SB 117
Creation of Kansas Transportation Network Company Services Act; House Sub. for SB 117 House Sub. for SB 117 creates the Kansas Transportation Network Company Services Act (Act). The bill defines applicable
TOWNSHIP OF LUMBERTON 35 Municipal Drive, Lumberton, New Jersey P. (609) / F. (609) NOTICE OF TORT CLAIM
TOWNSHIP OF LUMBERTON 35 Municipal Drive, Lumberton, New Jersey 08048 P. (609) 267-3217 / F. (609) 267-5566 www.lumbertontwp.com NOTICE OF TORT CLAIM CLAIMANT INFORMATION Name Address Telephone Date of
MAINE COMMUNITY COLLEGE SYSTEM
MAINE COMMUNITY COLLEGE SYSTEM HEALTH AND SAFETY Section 800.1 SUBJECT: PURPOSE: MOTOR VEHICLE PROCEDURE To promote the safe the authorized operation of motor vehicles operated on behalf, or for the benefit,
Accident and Incident Investigation Reporting
Page 1 of 6 Purpose: This policy establishes the procedures to be followed when a City of Mobile employee suffers a workplace injury, is involved in a vehicle accident, or is involved in any other incident
TOWNSHIP OF WEST ORANGE 66 MAIN STREET, WEST ORANGE, N.J
TOWNSHIP OF WEST ORANGE 66 MAIN STREET, WEST ORANGE, N.J. 07052 MUNICIPAL INSURANCE FUND COMMISSION ROBERT D. PARISI Tel: (973) 325-4050 Mayor Fax: (973) 736-8380 JOHN O. GROSS, M.P.A., C.M.F.O. Chairman
STANDARD TORT CLAIM FORM PACKET
STANDARD TORT CLAIM FORM PACKET Please carefully read all of the information in this packet before completing and presenting your tort claim. DOCUMENTS CONTAINED IN THE STANDARD TORT CLAIM FORM PACKET:
Standard Tort Claim Form Packet
Standard Tort Claim Form Packet Please carefully read all of the information in this packet before completing and presenting your Standard Tort Claim. A New Law that Impacts Presenting a Standard Tort
DRIVER SAFETY PROGRAM
South Central Louisiana Technical College YOUNG MEMORIAL CAMPUS 900 Youngs Road Morgan City, LA 70380 DRIVER SAFETY PROGRAM Contents Contents... 2 Management Policy Statement... 3 Conduct... 4 Administrative
CLAIM FORM MOTOR VEHICLE- CARAVAN - TRAILER
MULTIPLE DISTRICT 201 of LIONS CLUBS INTERNATIONAL Inc. CLAIM FORM MOTOR VEHICLE- CARAVAN - TRAILER Instructions to the Club completing this Claim Form: 1. In the event of an incident leading to a Claim,
Municipal Building 600 Bloomfield Avenue Verona, New Jersey Website: Date: Dear Claimant:
Municipal Building 600 Bloomfield Avenue Verona, New Jersey 07044 Website: www.veronanj.org OFFICE OF THE TOWNSHIP MANAGER Telephone: (973) 857-4767 Fax: (973) 857-4270 Email: Kgould@Veronanj.org Date:
APPLICATION CHECKLIST Motor Common Carrier or Motor Contract Carrier Of Household Goods in Use
APPLICATION CHECKLIST Motor Common Carrier or Motor Contract Carrier Of Household Goods in Use Use this checklist to make sure you have enclosed all required items or your application will not be processed.
APPLICATION CHECKLIST Motor Contract Carrier of Persons
APPLICATION CHECKLIST Motor Contract Carrier of Persons Use this checklist to make sure you have enclosed all required items or your application will not be processed. You cannot operate in Pennsylvania
APPLICATION CHECKLIST Transportation Network Service
APPLICATION CHECKLIST Transportation Network Service Use this checklist to make sure you have enclosed all required items or your application will not be processed. You cannot operate in Pennsylvania until
The Foust Firm, PLLC Jeffry B. Foust PERSONAL INJURY/AUTO ACCIDENT INTAKE SHEET INITIAL CLIENT STATEMENT
SOL: PERSONAL INJURY/AUTO ACCIDENT INTAKE SHEET INITIAL CLIENT STATEMENT HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE? IF SO, PLEASE GIVE NAME OF ATTORNEY: DO YOU HAVE A SIGNED RELEASE BY THAT ATTORNEY?
PERSONAL INJURY FULL NAME: HAVE YOU EVER USED OR BEEN KNOWN BY ANY OTHER NAME THAN THAT
DATE: INTAKE BY: SLIP & FALL AUTO ACCIDENT PERSONAL INJURY FULL NAME: IF MINOR PARENTS= NAMES: HAVE YOU EVER USED OR BEEN KNOWN BY ANY OTHER NAME THAN THAT SHOWN ABOVE? IF SO, PLEASE LIST EACH SUCH NAME,
AN ACT. Be it enacted by the General Assembly of the State of Ohio:
(131st General Assembly) (Substitute House Bill Number 237) AN ACT To amend section 4509.103 and to enact sections 3938.01, 3938.02, 3938.03, 3938.04, 4925.01, 4925.02, 4925.03, 4925.04, 4925.05, 4925.06,
Copies of this directive should be posted and distributed to all employees who may operate a state vehicle in the scope of their employment.
To: All Appointing Authorities and Personnel Officers From: of Administrative Services Re: State Self Insured Vehicle Liability Program PURPOSE Pursuant to section 9.83 of the Ohio Revised Code, the Office
IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI
IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI, ) ) Plaintiff, ) ) Cause No. vs. ) ) Division No., ) ) Defendant. ) DEFENDANT S APPROVED COMES NOW defendant pursuant to Local Court Rule
APPLICATION CHECKLIST Motor Common Carrier of Persons in Limousine Service
APPLICATION CHECKLIST Motor Common Carrier of Persons in Limousine Service Use this checklist to make sure you have enclosed all required items or your application will not be processed. You cannot operate
Accidental Death Claim Instructions
Phone : 1-877-722-1959 Fax: 443-279-2901 Accidental Death Claim Instructions The Claimant/ Insured should complete and sign the Accidental Death Insurance claim form in full and return it with the documentation
BOROUGH OF FLORHAM PARK Notice of Tort Claim Form
BOROUGH OF FLORHAM PARK Notice of Tort Claim Form General Instructions: Pursuant to the provisions of the New Jersey Tort Claims Act, this Notice of Tort Claim Form has been adopted as the official form
Basin Concrete & Trucking. Dear Basin Concrete Applicant,
Dear Basin Concrete Applicant, As part of our hiring process we have provided you with this application packet for you to complete. In order to make your hiring process flow as easily as possible the guidelines
LIABILITY CLAIM GUIDANCE NOTES
LIABILITY CLAIM GUIDANCE NOTES In the unfortunate event of a claim, we will do everything possible to deal with your claim promptly. In respect of claims made against you by any third party, for damage
Claim Form - Travel Insurance
Claim Form - Travel Insurance Important tice: To enable us to process your claim, please submit the duly completed claim form with supporting documents in original as listed in the subsequent section.
IN THE STATE COURT OF DEKALB COUNTY STATE OF GEORGIA
IN THE STATE COURT OF DEKALB COUNTY STATE OF GEORGIA JACKIE CARDIN AS SURVIVING SPOUSE OF MICHAEL LEE CARDIN, deceased, and JACKIE CARDIN AS ADMINISTRATOR OF THE ESTATE OF MICHAEL LEE CARDIN, deceased
LIABILITY CLAIM GUIDANCE NOTES
LIABILITY CLAIM GUIDANCE NOTES In the unfortunate event of a claim, we will do everything possible to deal with your claim promptly. In respect of claims made against you by any third party, for damage
2.8.1 VEHICLE USE POLICY FOR CONDUCTING THE OFFICIAL BUSINESS OF THE COLLEGE OF CHARLESTON. Policy Statement
OFFICIAL POLICY 2.8.1 VEHICLE USE POLICY FOR CONDUCTING THE OFFICIAL BUSINESS OF THE COLLEGE OF CHARLESTON 2/3/16 Policy Statement It is the Policy of the College to use motor vehicles in the performance
What happens if you have been involved in a road traffic collision?
What happens if you have been involved in a road traffic collision? We always complete a collision report if there are possible offences which will require investigation. In cases of non-injury collisions,
Owner Operator Application
Owner Operator Application Name: (first) (middle) (last) Current Address: (street /city) (state, zip) (how long?) Previous Addresses: (street /city) (state, zip) (how long?) (street /city) (state, zip)
APPLICATION CHECKLIST Motor Common Carrier of Persons in Group and Party Service Vehicles Seating 11 to 15 Passengers, including the Driver
APPLICATION CHECKLIST Motor Common Carrier of Persons in Group and Party Service Vehicles Seating 11 to 15 Passengers, including the Driver Use this checklist to make sure you have enclosed all required
Acquisition and Use of State Owned Motor Vehicles
Chapter 8 8.01 Authority. (a) These rules are adopted pursuant to O.C.G.A. 15-18-12(d)(2). (b) Generally these Rules are based on OPB and DOAS Policy Memorandum No. 10 (Revision 5), subject: Rules, Regulations
NOTICE OF CLAIM FORM FAXES & S WILL NOT BE ACCEPTED PLEASE RETURN BY HAND-DELIVERY, CERTIFIED AND/OR REGULAR MAIL
Joseph N. DiVincenzo, Jr. Essex County Executive OFFICE OF THE COUNTY COUNSEL Hall of Records, Room 535, Newark, New Jersey 07102 973.621.5003 --- 973.621.4599 (Fax) www.essexcountynj.org Courtney M. Gaccione
TRACY UNIFIED SCHOOL DISTRICT VOLUNTEER DRIVER REQUIREMENTS (Athletics / Field Trips)
TRACY UNIFIED SCHOOL DISTRICT VOLUNTEER DRIVER REQUIREMENTS (Athletics / Field Trips) Before you can use your personal vehicle to transport students on field trips or other school activities, you must
Chubb Travel Protection
Chubb Travel Protection Claim Forms Table of Contents Claim Form Page Main 1 Attending Physician Statement 9 Car Rental Collision Damage 12 Accidental Death & Dismemberment 17 Chubb Travel Protection Claim
TRAFFIC ACCIDENT INVESTIGATION
TRAFFIC ACCIDENT INVESTIGATION INDEX CODE: 1906 EFFECTIVE DATE: 07-11-17 Contents: I. Investigative Responsibility II. Accident Response III. First Officer on the Scene IV. Accident Investigation & Reporting
Pet Insurance Claim Form For Third Party Liability
Pet Insurance Claim Form For Third Party Liability Please send this form to Atlas Insurance PCC Limited Ta Xbiex Seafront, Ta Xbiex, Malta. PLEASE FILL IN ALL DETAILS and use BLOCK capitals throughout.
Colgate University Driver Safety and Motor Vehicle Use Policy
Purpose Colgate University Driver Safety and Motor Vehicle Use Policy This policy provides employee and student requirements for operation of Colgate University owned, leased, or rented motor vehicles,
NON INJURY ROAD TRAFFIC COLLISIONS
N INJURY ROAD TRAFFIC COLLISIONS Report of damage only collision A decision has been taken by the force that the majority of road traffic collisions where no injury has been caused will not be formally
Individual Transportation Participant (ITP) Enrollment Checklist
Individual Transportation Participant (ITP) Enrollment Checklist Use this checklist to make sure all the items needed to sign up to be an ITP are completed and submitted. No trips will be authorized until
Standard Tort Claim Form Packet
Standard Tort Claim Form Packet Please carefully read all of the information in this packet before completing and presenting your Standard Tort Claim. A New Law that Impacts Presenting a Standard Tort
. Union Environmental, LLC Driver Minimum Qualifications
. Union Environmental, LLC Driver Minimum Qualifications Please check each qualification you meet. All applicants must meet or exceed the following standards: Minimum age 24 2 years verifiable tractor/trailer
Worker s Compensation Investigation Kit Checklist
Worker s Compensation Investigation Kit Checklist Claim Handling Instructions Workers Compensation Instructions Employee Statement WC Accident Investigation Guide WC Activity-Communication Log Accident
The following document was obtained from the State of Georgia. This document may have changed since it was obtained. Please refer to the State's
The following document was obtained from the State of Georgia. This document may have changed since it was obtained. Please refer to the State's website for any updates at dds.georgia.gov GEORGIA DEPARTMENT
TRUCKING ACCIDENT CASES
Exceptional. Passionate. Trusted. PERSONAL I N J U RY AT T O R N E Y S T H E B E G I N N E R S G U I D E TO TRUCKING ACCIDENT CASES As trucking accident lawyers, we ve seen many unique cases through the
If you should have any questions about the process for obtaining your 2016 Occupational License please contact the City Hall:
Dear Home Occupation Owner: Attached is the application for a Home Occupation Tax Certificate. All Home Occupation Tax Certificates must be approved by City Council. Please note that the application must
Standard Tort Claim Form Packet
Standard Tort Claim Form Packet Please carefully read all of the information in this packet before completing and presenting your Standard Tort Claim. A New Law that Impacts Presenting a Standard Tort
To establish a policy for towing and storage services to be used by the City of West Kelowna and the West Kelowna RCMP Detachment.
CITY OF WEST KELOWNA COUNCIL POLICY MANUAL Pages: 1 of 5 Approval Date: January 9, 2018 SUBJECT: TOWING AND STORAGE SERVICE POLICY Purpose: To establish a policy for towing and storage services to be used
Travel Insurance Claim Form
IMPORTANT NOTE: Please answer all questions contained in this claim form as leaving items blank, using ticks, dashes and N/A may make it necessary for us to return your claim forms or lead us to ask more
Fund Organizational Chart
Fund Organizational Chart General Fund 1100 BOARD OF SUPERVISORS GOVERNMENTAL FUNDS Special Revenue Funds Capital Project Funds 1410 1420 PROPRIETARY FUNDS ELECTED DEPARTMENTS CLERK OF THE BOARD HEALTH
City of Cumming Police Department
Application for Certificate of Public Convenience Vehicles for Hire Instructions: Every question shall be fully answered. If the space provided is not sufficient, then continue the answer on a separate
Alamo Pressure Pumping, LLC
Driver Information Sheet Answer all questions PLEASE PRINT CLEARLY PLEASE SELECT ONE OF THE FOLLOWING: Company Driver Owner Operator Date of application: S.S. # First Middle Last Street State Zip Country
County of Monterey Vehicle Use Policy Revision 02/02
County of Monterey Vehicle Use Policy Revision 02/02 February 5, 2002 FEBRUARY 5, 2002 RETAIN UNTIL SUPERCEDED COUNTY OF MONTEREY VEHICLE USE POLICY & PROCEDURES Table of Contents I) Introduction 1 II)
THE INTEGRITY CENTER objective risk management information A Unit of Integrity Centers Corporation
THE INTEGRITY CENTER objective risk management information A Unit of Integrity Centers Corporation TM Suite 1008 2828 Forest Lane Dallas, Texas 75234 (972) 484-6140 (800) 456-1811 FAX (972) 484-6381 http://www.integctr.com/
Send this signed form and any accompanying documents to Seven Corners within 180 days from the date of service using any of the following methods:
Claim Form Please submit this completed Claim form with the itemized bills and receipts. A separate Claim Form is needed for each member. Please tape small receipts on a full size sheet of paper. Failure
ALABAMA PRIVATE PASSENGER AUTO. June 1, 2015 TABLE OF CONTENTS
ALABAMA PRIVATE PASSENGER AUTO June 1, 2015 TABLE OF CONTENTS 1. Definitions 2 2. Personal Automobile Policy-Eligibility. 2-3 3. Premium Determination 3 4. Classifications. 4-8 5. Driving Record Points...
Motor Vehicle Claim Form
Motor Vehicle Claim Form (The issue of this form is not an admission of liability) This form should be completed and forwarded to Echelon Claims Services Please tick boxes where appropriate Trust Name:
Claim Form GROUP PTY LTD. RSM GROUP Pty Ltd - Wholesale Broking
GROUP PTY LTD Claim Form RSM GROUP Pty Ltd - Wholesale Broking ABN 40 006 361 226 AFS Licence No. 239631 380-382 Canterbury Road, Surrey Hills Vic 3127 Private Bag 4000 Surrey Hills Vic 3127 T: (03) 9276
Boomerang Tablet I. Covenants/Rules
Boomerang Tablet I. Covenants/Rules You are to conduct yourself in an ethical manner and treat all Boomerang property as if it were your own You are to treat all Boomerang customers with the respect and
As Reported by the Senate State and Local Government Committee. 131st General Assembly Regular Session Sub. H. B. No.
131st General Assembly Regular Session Sub. H. B. No. 237 2015-2016 Representatives Duffey, Hackett Cosponsors: Representatives Bishoff, Amstutz, Anielski, Antani, Antonio, Ashford, Buchy, Burkley, Derickson,
ADDENDUM C VEHICLE OPERATIONS POLICY
ADDENDUM C VEHICLE OPERATIONS POLICY 1 VEHICLE OPERATIONS POLICY (from the Shasta County Personnel Rules, Chapter 33) SECTION 33.1. PURPOSE. Vehicle accidents pose a significant threat to public and personal
Boomerang Transport, LLC Independent Contractor Agreement
Boomerang Transport, LLC Independent Contractor Agreement This independent Contractor Agreement is made and entered into as of this day of 20. By and between Boomerang Transport, LLC a North Carolina Limited
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 657/15
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 657/15 BEFORE: R. Nairn: Vice-Chair HEARING: April 29, 2016 at Toronto Oral DATE OF DECISION: August 10, 2016 NEUTRAL CITATION: 2016 ONWSIAT
GROUP LIFE AND/OR ACCIDENTAL DEATH CLAIM FORM
OUR COMMITMENT For use with policies issued by the following Unum Group [ Unum ] subsidiaries: Unum Life Insurance Company of America Provident Life and Accident Insurance Company The Paul Revere Life
12.3 Motor Vehicles Disposal of State Vehicles
1. Authority and Application. (a) (b) (c) This Policy is adopted pursuant to the authority granted to the Council pursuant to the provisions of O.C.G.A. 15-18-12(d)(2); 15-18-40(c); and 15-18-44(c) and
City of Park Ridge Revenue Rates
City of Park Ridge Revenue s Emergency Telephone Emergency Telephone Emergency Telephone System Surcharge Prepaid Wireless 911 Surcharge Property Tax Road & Bridge Tax 2-2-1 A surcharge is hereby imposed
A Bill Regular Session, 2015 SENATE BILL 800
Stricken language would be deleted from and underlined language would be added to present law. 0 State of Arkansas 0th General Assembly As Engrossed: S// A Bill Regular Session, SENATE BILL 00 By: Senator
Special Car Insurance Conditions Limited comprehensive
01. WHO ARE INSURED? The insurance applies to all people listed below. These people are referred to as you in the conditions set out below. The person taking out this insurance. The person who uses the
Summer Camp Application INTERNATIONAL DEVELOPMENT 101
INTERNATIONAL DEVELOPMENT 101 Student Information Student Name: Sex : Male / Female Student Preferred/Nickname: Mailing Address: Home Phone Number: Cell Phone Number: School: Grade (Entering): Date of
UCLA Procedure 300.3: University Owned or Leased Motor Vehicles: Physical Damage Insurance Coverage, Accident Reporting, and Claim Procedures
UCLA Procedure 300.3: University Owned or Leased Motor Vehicles: Physical Damage Insurance Coverage, Accident Reporting, and Claim Procedures Issuing Officer: Associate Vice Chancellor, Business & Financial
PERSONAL ACCIDENT OR SICKNESS CLAIM FORM
PERSONAL ACCIDENT OR SICKNESS CLAIM FORM This form must be completed truthfully and accurately. The list of documents required is not exhaustive and we reserve our right to request from you any additional
STONY RUN ENTERPRISES
STONY RUN ENTERPRISES Please follow these instructions for filling out the application. 1. Please save a blank copy of the form to your computer before filling it out. 2. Fill out the full application,
New York Life Insurance Company
The Company You Keep New York Life Insurance Company Group Membership Association Claims PO Box 30782 Tampa FL 33630-3782 (800) 792-9686 Dear Beneficiary: Please accept our condolences on your recent loss.
California General Interrogatories (Wrongful Death) DEFINITIONS. 1. AREA means the name of the specific structure, building, building
California General Interrogatories (Wrongful Death) DEFINITIONS 1. AREA means the name of the specific structure, building, building number, floor of the building, ship compartment, process line, unit,
YOUR GUIDE TO CLAIMS REPORTING
YOUR GUIDE TO CLAIMS REPORTING...SEEING YOU THROUGH PHONE: 888.433.3553 FAX: 410.433.3440 TABLE OF CONTENTS 1 WELCOME 2 POLICY AND CLAIMS OVERVIEW 3 AUTOMOBILE CLAIMS 4 AUTOMOBILE CLAIMS FORM 5 PROPERTY
ADDENDUM #2. The following questions, concerns or request for clarification have been raised.
PURCHASING DEPARTMENT 151 Willowbend Road Peachtree City, GA 30269 Phone: 770-487-7657 Fax: 770-631-2505 www.peachtree-city.org CITY OF PEACHTREE CITY RFP # 13-124PAS FIRE & POLICE (PUBLIC SAFETY) ORGANIZATIONAL
Senior Vice President for Administration and Chief Operating Officer
NUMBER: VMPS 6.00 SECTION: SUBJECT: Vehicle Management and Parking Services Vehicle Insurance and Accident Policy DATE: December 9, 2010 REVISED: September 2, 2016 Policy for: Procedure for: Authorized
INSTRUCTION SHEET: APPLICATION FOR CLASS B PASSENGER CARRIER CERTIFICATE
GEORGIA DEPARTMENT OF PUBLIC SAFETY MCCD REGULATIONS COMPLIANCE P.O. BOX 1456 ATLANTA, GEORGIA 30371 (404) 624-7244 OR (404) 624-7243 FAX: (404) 624-7246 www.gamccd.net INSTRUCTION SHEET: APPLICATION FOR
Vehicle Use Policy. 2. Authority: The Clinton County Board of Commissioners.
1. Purpose: This policy establishes procedures regarding the assignment of County vehicles, use of County vehicles, and business use of private vehicles. For insurance and liability issues as well as good
May be furnished by any three (3) persons who have known the applicant (agent) for at least three (3) years. Include name, address & phone number.
Two Original Applications Personal History Form Lease or Valid Document Photographs Corporate Papers Letters of Reference Financial Investments Please write legibly in BLACK ink or type information. Answer
Massachusetts Automobile Insurance Policy
Massachusetts Automobile Insurance Policy Please read your policy. As you read the policy, check the Coverage Selections Page to make sure it shows exactly what you intended to buy. If there is any question,
Tideport Distributing, Inc De Zavala Rd Channelview, TX Phone: Fax:
Tideport Distributing, Inc. 16031 De Zavala Rd Channelview, TX 77530 Phone: 281-862-9668 Fax: 281-452-2865 ALL APPLICANTS _ In accordance with Federal regulations, please fill-in this application so that
Application for Driver
48 Spiller Drive Westbrook, ME 04062 207-775-2676 Fax: 207-775-2896 Email: ccaplice@sigcoinc.com Application for Driver Personal Information Date Last Name First Name MI Address City State Zip Code Home
PERSONAL INJURY CASES
Exceptional. Passionate. Trusted. PERSONAL INJURY ATTORNEYS THE BEGINNER S GUIDE TO PERSONAL INJURY CASES As personal injury lawyers, we ve seen many unique cases through the years. We ve found that an
Volunteer Drivers: Information and Application
SOU WEST NOVA TRANSIT ASSOCIATION Volunteer Drivers: Information and Application Thank you for your interest in becoming a volunteer for the Volunteer Driver Program! The contributions of people like you
THOROUGHBRED LAKES HOA BUYER CHECKLIST
THOROUGHBRED LAKES HOA BUYER CHECKLIST BELOW IS A LIST OF ITEMS NEEDED TO PURCHASE A HOME. PLEASE INDICATE WITH A CHECK MARK THAT THE NEEDED ITEMS ARE ENCLOSED. IF YOU FAIL TO PROVIDE ALL INFORMATION AND
STANDARD TORT CLAIM FORM PLEASE TYPE OR PRINT IN INK
STANDARD TORT CLAIM FORM PLEASE TYPE OR PRINT IN INK General Liability Claim Form Pursuant to Chapter 4.92 RCW, this form is for filing a tort claim against the Public Utility District No. 3 of Mason County.
WYOMING AUTOMOBILE INSURANCE GUIDE
WYOMING AUTOMOBILE INSURANCE GUIDE TO ASSIST YOU Wyoming Insurance Department 106 East 6 th Avenue Cheyenne, WY 82002 (307) 777-7401 1-800-438-5768 (Wyoming only) TABLE OF CONTENTS Is Auto Insurance Mandatory?...4
Virginia Department of Education
Virginia Department of Education Module Ten Transparencies Driver Responsibilities: Making Informed Choices Topic 1 -- Insuring Vehicle Topic 2 -- Purchasing Vehicle Topic 3 -- Trip Planning Topic 4 Virginia
H2P CAR INSURANCE MOTOR ACCIDENT CLAIM FORM
H2P CAR INSURANCE MOTOR ACCIDENT CLAIM FORM CLAIM NUMBER NAME OF CLAIMS OFFICER PHONE NUMBER IMPORTANT INFORMATION ABOUT MAKING A CLAIM 1. Please ensure PERSONAL INFORMATION is read before signing the
Claim Information and Instructions
CIVIL DIVISION Columbus, Ohio 43215-9013 614-645-7385 Fax: 614-724-6503 CLAIMS DIVISION Columbus, Ohio 43215-9013 614-645-7385 Fax: 614-645-2291 General Information ZACH KLEIN COLUMBUS CITY ATTORNEY Claim
SUBMISSION AND RECOVERY OF PROPERTY DAMAGE CLAIMS
Approved: Effective: August 16, 2017 Review: April 21, 2017 Office of the General Counsel Topic No.: 225-085-002-e Department of Transportation PURPOSE: SUBMISSION AND RECOVERY OF PROPERTY DAMAGE CLAIMS
CRIME VICTIM COMPENSATION APPLICATION
CRIME VICTIM COMPENSATION APPLICATION Weld County District Attorney s Office Michael J. Rourke -District Attorney Post Office Box 1167 915 Tenth Street Greeley, CO 80632 (970) 356-4010 Fax (970) 336-7224
The Auto Claim Experience and Accident Worksheet
The Auto Claim Experience and Accident Worksheet Personal Risk Services We will help you through the auto claim process quickly and efficiently, with professionalism and compassion. Here When You Need
APPLICATION FOR CONTRACT SERVICES
APPLICATION FOR CONTRACT SERVICES Location applying for: Date: OWNER OPERATOR COMPANY INFORMATION This section must be filled out on the original application by the Owner Operator. Drivers for the Owner