NOTICE OF TORT CLAIM
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FOR BOROUGH OF HAWORTH
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CLAIMANT INFORMATION
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Name
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_____________________
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Telephone
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_____________________
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Address
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_____________________
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Date of Birth
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_____________________
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_____________________
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Soc. Sec. No.
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_____________________
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ATTORNEY INFORMATION (if applicable)
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Name
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_____________________
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Telephone
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_____________________
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Address
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_____________________
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FAX No.
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_____________________
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_____________________
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File No.
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_____________________
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Send Notices to:
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_________
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Claimant
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______________
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Attorney
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______________
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INTERROGATORIES AND DOCUMENT REQUESTS
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GENERAL INSTRUCTIONS: The Borough of Haworth, pursuant to the
provisions of the New Jersey Tort Claims Act, has adopted this form
including these written interrogatories and requests for the production
of documents as the official form for the filing of claims against
the Borough of Haworth.
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The written interrogatories are to be answered by the Claimant
to the extent of all information available to the Claimant or his
attorneys, agents, servants, and employees, under oath. The answers
to these interrogatories and the documents requested shall be returned
to the Borough of Haworth, Municipal Building, Haworth, New Jersey
07641.
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Your claim will not be considered filed as required by the New
Jersey Tort Claims Act until this completed form has been filed with
the Borough of Haworth.
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This form is designed as a general form for use with respect
to all claims. Some of the questions may not be applicable to your
particular claim. For example, if your claim does not arise out of
an automobile accident, questions regarding road conditions might
not be applicable. In that event, you should so specify in the space
where an answer is to be provided to that question.
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A. When, after a reasonable and thorough investigation using
due diligence, you are unable to answer any interrogatory, or any
part thereof, because of lack of information available to you, specify
in full and complete detail the reason the information is not available
to you and what has been done to locate the information. In addition,
specify what knowledge or belief you have concerning the unanswered
portion of the interrogatory and set forth the facts upon which the
knowledge or belief is based.
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B. When an interrogatory asks that you identify writings, it
shall be deemed a sufficient answer, where appropriate and possible,
to furnish true and legible copies thereof, together with your answers
to these interrogatories.
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C. Where an interrogatory does not specifically request a particular
fact, but where the facts are necessary in order to make the answer
to the interrogatory either comprehensible, complete or not misleading,
you are requested to include the fact or facts as part of the answer
and the interrogatory shall be deemed specifically to request the
fact or facts.
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D. If you claim any form of privilege, whether based on Statute
or otherwise, as a ground for not answering an interrogatory, or any
part thereof, set forth in complete detail each and every fact upon
which the privilege is based, including sufficient facts for the Court
to make a full determination whether the claim of privilege is valid.
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E. Where an interrogatory asks for a date or an amount or any
other specific information, it will not be adequate to state that
the precise date, amount or other specific information is unknown
to you, where you are capable of approximating the information requested.
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F. Where an interrogatory requests that you "identify all writings,"
you should state with specificity the date, author, description, addressee
(if any), nature, custodian, and location of the writings referred
to by the interrogatory, as well as the substance of the writing.
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G. When an interrogatory asks that you "identify all oral communications",
you should state, with respect to every oral communication, the description
of which is required by the interrogatory, (I) the date and place
thereof, (II) who initiated the communication, (III) whether the communication
was in person or by telephone or other form of transmission and specify
which, (IV) the name, home address and telephone number, business
address and telephone number, employer (present or last known), job
title, occupation of each and every person who participated in the
communication.
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H. Where an interrogatory asks that you "identify all persons",
state the name and present or last known business and residence address
and telephone numbers, occupation and title, if any, of person whose
identity is sought by the interrogatory.
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I. For the purposes of these interrogatories, "Person" shall
include in its meaning a partnership, joint venture, corporation,
association, trust or any other kind of entity, as well as a natural
person.
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J. If any document to be produced in response to these interrogatories
contains information which must be treated as confidential in nature,
identify that document and state the reason for the confidentiality.
The Borough of Haworth and the attorneys for the Borough of Haworth
hereby warrant to the Claimant that the confidentiality of any document
so identified will be respected, guarded and maintained until the
time as a Court having jurisdiction over the issue may rule on any
disputed issue of confidentiality.
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K. These interrogatories request documents which are relevant
to the subject matter of the claims and allegations of the Claimant.
To the extent that any document does not relate in its entirety to
the subject matter of the Claimant's claims or allegations, the document
may be withheld. All other documents which deal directly with the
subject matter of the Claimant's claims or allegations must be produced
in response to these requests.
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L. All responses to interrogatories or objections thereto shall
be prefaced by the particular interrogatory or subsection thereof.
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M. An attempt has been made to provide adequate space for the
answers to interrogatories. However, should you need more space to
provide a fully responsive answer, please attach supplementary pages,
identifying the continuation of the answer with the number of the
applicable interrogatory.
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N. All documents produced shall be labeled and referenced to
a particular document request or interrogatory. If the documents are
produced in response to more than one interrogatory, this fact should
be noted as well.
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O. The interrogatories and document requests shall be deemed
continuing, so as to require supplemental answers from time to time
up to the date of a trial, in the event that the claim results in
litigation.
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Definitions: As used herein "documents" shall refer to any written,
recorded or graphic representation, either produced or reproduced,
and any copy thereof, including, but not limited to, letters, memoranda,
notes, minutes, summaries, forecasts, appraisals, surveys, calculations,
inter-office communications, diaries, work sheets, telegrams, cables,
telex messages, written agreements, invoices, press releases, books,
records, financial statements, tapes, computer print-outs, computer
tapes and/or disks, computer programs, drafts of any of the foregoing,
magazines and other publications and any material underlying, supporting
or used in the preparation of any documents, now or formerly in actual
or constructive possession, custody or control of the deponent, and
all copies thereof where the copy is not an identical copy of the
original, such as where the copy contains written notations.
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As used herein, "Claimant" shall refer to the person or persons
on whose behalf the Notice of Claim has been filed with the Borough
of Haworth.
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As used herein, "Borough of Haworth" shall refer to the Borough
of Haworth along with any agent, official or employee of the Borough
of Haworth against whom a claim is asserted by the Claimant.
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1. Set forth the present residence address and telephone number
of the Claimant and identify each person residing at the same address
and the relation, if any, the person has to the Claimant.
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2. Set forth all prior addresses of the Claimant, the dates
of the residence, the persons residing at the addresses at the same
time as the Claimant resided at the address and the relation, if any,
of the person to the Claimant.
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3. Set forth the date of birth, social security number, marital
status at the time of the injury and the present marital status of
the Claimant.
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4. Set forth the exact date, time and place of the injury forming
the basis of the complaint and the weather conditions prevailing at
the time.
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5. Set forth in complete detail in narrative form, the Claimant's
version of the events that form the basis of the complaint, specifically
setting forth the names and addresses of all participants and witnesses
and the nature and extent of the participation of any individual so
identified.
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6. Set forth any and all individuals who were witnesses to or
who have knowledge of the facts of the incident which gave rise to
the complaint. Provide the full name and all data as required by the
instructions preceding these interrogatories.
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7. Identify all public entities or public employees alleged
to have caused the injury and specify as to each public entity or
employee the act or omission alleged to have caused the injury.
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8. Identify and provide copies of all documents, memoranda,
correspondence, reports, etc. which discuss, mention or pertain to
the subject matter of this litigation.
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9. Describe in detail the nature, extent and duration of any
and all injuries.
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10. Describe in detail any injury or condition claimed to be
permanent or residual, together with all present complaints.
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11. If confined to any hospitals, state name and address of
each and the dates of admission and discharge therefrom. Include all
hospital admissions prior to and subsequent to the alleged injury
forming the basis of the complaint and set forth the reason for each
admission.
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12. If x-rays were taken, state (a) the address of the place
where each was taken; (b) the name and address of the person who took
them; (c) the date when each was taken; (d) what each disclosed; (e)
where and in whose possession they now are. Include all x-rays, whether
prior to or subsequent to the alleged injury forming the basis of
the complaint.
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13. If treated by doctors, state (a) the name and present address
of each doctor; (b) the dates and places where treatments were received;
(c) the date of last treatment. Annex true copies of all written reports
rendered to you about you by any doctors whom you propose to have
testify on your behalf.
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14. If you have ever been treated by or have consulted with
a psychologist, psychiatrist, social worker, family counselor, or
marriage counselor, set forth the name and address of the psychologist,
psychiatrist, social worker, family counselor or marriage counselor,
the dates of each consultation or treatment, the reasons for the consultation
or treatment and the date of discharge from the treatment, and attach
true copies of all written reports rendered to you about you by any
psychologists, psychiatrists, social workers, family counselors or
marriage counselors.
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15. If you are still being treated, state (a) the name and address
of each professional as set forth in question 14 rendering treatment;
(b) the nature thereof and (c) where and how often the treatment is
received.
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16. If you claim that a previous injury, disease or illness
has been aggravated, accelerated or exacerbated, state in detail the
nature of each and the name and present address of each doctor who
rendered treatment for the condition.
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17. If you have any physical impairment affecting your ordinary
movements, hearing or sight, state in detail the nature and extent
of the impairment and what corrective appliances, support or device
you use to overcome or alleviate the impairment.
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18. If any treatments, operation or other form of survey in
the future has been recommended, suggested or advised to cure, correct,
remedy or alleviate any injury or condition resulting from the incident
which forms the basis of the complaint, state in detail (a) the nature
and extent of the treatment, operation or surgery; (b) the purpose
thereof and the results anticipated or expected; (c) the name and
address of the doctor who recommended or suggested or advised the
treatments, operation or surgery; (d) the name and address of the
doctor who will administer or perform same; (e) the estimated medical
expenses and disbursements to be incurred thereby; (f) the estimated
length of time of treatments, operation or surgery, period of hospitalization
and period of convalescence; (g) all other losses or expenditures
anticipated as a result of the treatments, operation or surgery; (h)
whether it is your intention to undergo the treatments, operation
or surgery and the approximate date.
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19. Itemize any and all monies expended or expenses incurred
for hospitals, doctors, nurses, x-rays, medicines, care and appliances
and state the name and address of each payee and the amount paid or
owed each payee.
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20. Itemize any and all future medical or other expenses to
be incurred, not otherwise set forth herein.
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21. If employed at the time of alleged injury forming the basis
of the complaint, state (a) the name and address of the employer;
(b) position held and the nature of the work performed; (c) average
weekly wages for the year prior to the injury; (d) period of time
lost from employment, giving dates; (e) amount of wages lost, if any.
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22. If other loss of income, profit or earnings is claimed,
state (a) total amount of the loss; (b) give a complete detailed computation
of the loss; (c) the nature and source of loss of the income, profit
and earnings and dates of deprivation thereof.
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23. If you are presently employed, state (a) the date that the
employment began; (b) the name and address of the employer; (c) the
position held and the nature of the work performed; (d) the average
weekly wages. Attach copies of pay stubs or other complete payroll
record for all wages received during the past year.
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24. If you have received any money or thing of value for your
injuries or damages from any person, firm or corporation, state the
amounts received, the dates, names and addresses of the payors.
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25. If any photographs, sketches, charts or maps were made with
respect to anything which is the subject matter of the claim, state
the date thereof, the names and addresses of the persons making the
same and of the persons who have present possession thereof. Attach
copies of any photographs, sketches, charts or maps upon which you
intend to rely.
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26. State the names and addresses of all persons who have knowledge
of any relevant facts relating to the case, identify each person whom
you intend to call as a witness, and set forth as to each person the
nature of the testimony that you expect them to present.
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27. If you or any of the parties to this action or any of the
witnesses made any statements or admissions, set forth what was said;
by whom said; date and place where said; and in whose presence, giving
names and addresses of any person having knowledge thereof.
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28. With respect to all expert witnesses, including treating
physicians who are expected to support the claim of the claimant,
and with respect to any person who has conducted an examination of
the claimant and who may be called upon to testify in any proceeding
with respect to the claim, state the witness's name, address and area
of expertise and annex a true copy of all written reports rendered
to or about you. If a report is not written, supply a summary of any
oral report.
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29. If you, or any other party or witness you propose to produce,
consumed any alcoholic beverages or any drugs or medications within
six hours before the incident forming the basis of the complaint,
state (a) the person consuming the same and for each person, (b) what
was consumed; (c) the quantity thereof; (d) where consumed; (e) the
names and addresses of all persons present.
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30. With respect to the alleged injury forming the basis of
the complaint, was any complaint made to the Borough of Haworth.
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31. If the answer to question 30 above is in the affirmative,
state the time and place of the complaint and the person or persons
to whom the complaint was made.
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32. If you allege wrongdoing by any employee or official of
the Borough of Haworth against which the claim is being filed, set
forth the name and position of the employee or official, the exact
nature of the alleged wrongdoing, whether any complaint was filed
against the official or employee, with whom the complaint was filed
and, if no complaint was filed, the reason for the failure to file
the complaint.
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33. Set forth the amount of your claim and the basis on which
you calculate the amount claimed.
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DOCUMENT REQUEST: Produce all documents identified in your answers
to the above interrogatories.
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CERTIFICATION
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The undersigned, identified as the claimant for the purpose
of the above claim, hereby certifies that the information provided
is the truth and is the full and complete response to the interrogatories,
to the best of the knowledge, information and belief to the undersigned.
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_____________________________________
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Dated:
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__________________
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AUTHORIZATION FOR RELEASE OF MEDICAL AND HOSPITAL RECORDS
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TO: __________________
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DATE:__________________
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RE:
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Patient's Name:
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Address
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You are hereby authorized and requested to disclose, make available
and furnish to the Attorney for the Borough of Haworth whose address
is: _____________________________ or to the authorized representative
of the Borough of Haworth, all information, records, x-rays, reports
or copies thereof relating to my examination, consultation, confinement
or treatment and to permit him or her to inspect and make copies or
abstracts thereof. Approximate date of admission to hospital, first
examination, treatment or consultation. A photocopy of this release
form, bearing a photocopy of my signature, shall constitute your authorization
for the release of the information in accordance with the request
made to you.
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