[HISTORY: Adopted by the Board of Chosen Freeholders of Atlantic County 7-17-1984 by Ord. No. 12-1984. Amendments noted where applicable.]
The County Counsel shall develop and file with the County Executive and the Clerk to this Board a form entitled "Notice of Claim for Damages Against the County of Atlantic."
Said form shall contain appropriate blanks for all of the following information, but shall not be limited in scope hereby:
The name and post office address of the claimant.
The post office address to which the person presenting the claim desires notices to be sent.
The date of the occurrence.
The place of the occurrence.
A full and complete description of the circumstances of the occurrence, setting forth specifically and in detail all facts and legal theories upon which the claimant asserts liability against the County of Atlantic and/or its officers and employees.
To the extent known by the claimant, the name and/or job title and/or function of the employee or employees alleged to have caused the damage or injury, stating specifically the manner in which the actions or failures to act of said employees are alleged to have proximately caused the occurrence.
The amount of money claimed by the claimant to be total compensation for the injury suffered, as of the date of claim, together with a statement setting forth the method of computation of the amount, detailed as follows:
All amounts claimed for property damages, stating the source or sources from which valuation was derived.
All amounts claimed as medical expenses up to date of claim.
All amounts claimed as damages for pain and suffering.
All amounts claimed as lost wages as a result of the occurrence, as of the date of claim.
Estimated future medical expenses, with a detailed statement of anticipated expenses and the source of the information.
Estimated future lost wages, stating specifically the means of computation of said lost wages, including the amount of previous and present wages on an annual basis and the duration of diminished earning capacity.
The claimant shall attach copies of the following to the notice of claim required hereunder:
Written reports of all examining and/or treating medical, dental or other health care professionals, setting forth the following
The nature and extent of injury.
Detailing all treatment given to the date of claim.
Stating specifically and in detail the type and cause of all temporary disability resulting from the occurrence.
Stating specifically and in detail the type and cause of all permanent disability which will, in the treating physician's judgment, result from the injury sustained.
A detailed prognosis, stating at which point in time any temporary disability will be resolved.
The period of hospitalization of the claimant, if any.
Any limitation, temporary or permanent, on the claimant's ability to pursue his or her employment as a result of the injuries and the extent and duration of any such limitation.
A list of the names and addresses of all expert witnesses, together with copies of all reports rendered in writing with respect to the claim and a summary of all oral reports or statements.
Complete and itemized bills and/or receipts for all medical, dental and hospital expenses incurred.
Copies of the claimant's federal income tax returns for the two tax years preceding the date of claim. Alternatively, the claimant may attach other documentary proof of amounts of income lost and advise the county as to where and when the claimant's federal tax returns may be inspected by representatives of the county.
A statement by a treating physician as to whether future treatment will be necessary and, if so, detailing the nature, expected duration and result of such treatment.
The claimant shall include his or her signature on an authorization to be submitted as part of the notice of claim, consenting to physical and/or mental examination by a physician employed by the county and to inspection and copying of all appropriate records relating to his or her claim for liability and damages, including, but not related to, income tax returns, hospital records, medical records and employment records. The claimant shall provide a telephone number through which arrangement for medical examinations and examination of records may be made during regular business hours.
The notice of claim shall provide in the area for the claimant's signature the following language: "I have read this form in its entirety and acknowledge that the purpose of completing this form is to make written application for pecuniary benefit and is to aid officials of the County of Atlantic in performing their lawful function. I recognize that the New Jersey Code of Criminal Justice, N.J.S.A. 2C:28-3(b) makes it a disorderly persons offense to make any written false statement which I do not believe to be true, or to omit information with purpose either to create a false impression or to mislead the public officials in the performance of their functions. I recognize that the information supplied herein will be used by public officials to evaluate the monetary value of this claim, and that a six-month period is provided by law (N.J.S.A. 59:8-8) for review of this claim by the public entity before I may file suit. If I should, either personally or through my attorney, receive information or obtain documents that would render any statement made herein false, misleading, or incomplete I will cause this material to be forwarded to the County as soon as possible. I certify that I have read this completed Notice of Claim for Damages and that all information contained herein is true and complete except as noted otherwise in my answers."
The notice of claim specified hereunder shall be signed by the claimant or a person acting on behalf of the claimant. All statements made in the notice of claim specified hereunder shall, in all events, be binding upon the claimant for all purposes unless disclaimed specifically and in writing.
The notice of claim specified hereunder shall be filed by the claimant within 30 days after the claimant has received the form from the county. The county shall send the form by certified mail to the address stated for receipt of mail in the initial notice of claim.
A cover letter outlining in brief form the provisions of this chapter shall accompany the form sent to the claimant.
Compliance with the provisions of this chapter shall be considered a part of the claims procedure required pursuant to N.J.S.A. 59:8-3 and other relevant sections of the New Jersey Tort Claims Act.