In the aftermath of the unfortunate incident on August 13, 2011, at the Indiana State Fair, the OAG 795549 form serves a crucial role in facilitating claims related to physical injuries or death. This detailed document, revised in September 2011, is a vital tool for individuals seeking to navigate the complexities of lodging a tort claim with the state. It outlines a clear process, starting from submission to the designated State Fair Tort Claim Administrator, housed at JWF Specialty under the attention of Heather Hunter in Indianapolis, Indiana. The form stipulates a submission deadline, underscoring the need for timely action. Moreover, it emphasizes the necessity of providing comprehensive information to assist in swift claim processing, offering guidance and support through contact information for assistance. As it navigates claimants through sections dedicated to personal information, details about the injured person or decedent, additional relevant information, and the method of payment, the form underscores the importance of transparency and accuracy. This is further highlighted by the requirement for claimants to certify the truthfulness and accuracy of the provided information, a step aimed at ensuring integrity in the claims process. Additionally, the form accommodates individuals' preferences for payment method, including an option for electronic fund transfer, demonstrating adaptability to modern needs while also providing an option to waive such requirements for those who prefer or require a traditional check payment. The OAG 795549 form ultimately represents a structured pathway for affected individuals to seek relief and compensation through the Indiana State Fair Tort Claim, reflecting the state's commitment to addressing the consequences of the tragic event.
| Question | Answer |
|---|---|
| Form Name | Oag Form 795549 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | 96th, 2011, Eileen, tort claims examples |
INDIANA STATE FAIR TORT CLAIM FORM
Physical Injury or Death from Incident on August 13, 2011
OAG Form: 795549/Rev.
RETURN COMPLETED FORM by mail to:
STATE FAIR TORT CLAIM ADMINISTRATOR
C/O JWF Specialty
Attn: Heather Hunter
600 E. 96th Street, Suite 425
Indianapolis, IN 46240
INSTRUCTIONS: |
1. |
Deadline for Submission of this form is Tuesday, November 1, 2011. |
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To assist us in responding to your claim as soon as possible, please help us by completing the |
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information requested in the form below. |
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3. |
If you need assistance in completing this form, please call |
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• Heather Hunter – heather.hunter@oldnationalins.com, or |
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• Eileen Carroll – eileen.carroll@oldnationalins.com |
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Sign, date and return this form to the address in the upper right corner above. |
NOTES: |
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Use this form to make a claim to the Tort Claim Fund under IC |
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To apply for gift distributions from the Indiana State Relief Fund contact the Indiana State Fair Commission. |
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● All information provided in Sections 1 through 4 is subject to Public Access under the Indiana Access to |
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Public Records Act, Indiana Code |
SECTION 1: Claimant Information
Are you filing this claim on behalf of yourself?
Yes Complete Section 1, and skip to Section 3
No Complete all sections and state your relationship to the injured person or decedent
Relationship to Injured Person or Decedent
Last Name |
First Name |
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Address |
City |
State Zip |
Phone Number (Day)
Phone Number (Evening)
Phone Number (Cell)
Email Address:
SECTION 2: Information for
Last Name |
First Name |
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Address |
City |
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State Zip |
SECTION 3: Additional Information Regarding the Claimant, Injured Person or Decedent
Hospital(s) and/or Medical Provider(s) |
Please attach supporting documentation if available. |
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Was Claimant, Injured Person or Decedent hospitalized and/or received any medical treatment? |
No |
Yes |
Still Hospitalized |
If Yes, in the area below please state the hospital/facility name and total days admitted. |
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If Still Hospitalized please enter "SH" in the "Days" column. |
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Hospital(s) and/or Medical Provider(s)
Days
Did death occur as a result of the incident?, If Yes, please enter the date of death
No
Yes
Date (m/d/yyyy)
INDIANA STATE FAIR TORT CLAIM FORM
Physical Injury or Death from Incident on August 13, 2011
OAG Form: 795549/Rev.
RETURN COMPLETED FORM by mail to:
STATE FAIR TORT CLAIM ADMINISTRATOR
C/O JWF Specialty
Attn: Heather Hunter
600 E. 96th Street, Suite 425
Indianapolis, IN 46240
SECTION 3: Additional Information Regarding the Claimant, Injured Person or Decedent
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Date of Birth (m/d/yyyy) |
Occupation: |
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Income Range: |
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Under $50,000 |
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101,000 and Over |
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Marital Status |
Number of Dependents: |
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Education |
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Single |
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Some High School |
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Dependent Name |
Age |
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Married |
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High School Graduate |
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Divorced |
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Some College |
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Head of Household |
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College Graduate |
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Degrees Earned: |
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Yes |
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No |
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Please enter a brief description of the job duties of the occupation: |
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Did the Injured Person miss work? If Yes, please enter the number of work days missed and employer name and address
Missed Work?
Days Missed
Employer Name
Employer Address
No
Yes
Still not back to work
Please provide a brief description of the nature and extent of the injuries and the impact these injuries have had or are reasonably expected to have.
SECTION 4: Signature
I hereby certify that the information provided in this claim form application is true and accurate to the best of my knowledge and I am authorized to file this claim. I also authorize the State of Indiana to use information contained in this form for purposes of State Form 53788 (Information necessary to distribute payments from the state).
Claimant Printed Name |
Claimant Signature |
Date (m/d/yyyy) |
Claimant Name: |
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INDIANA STATE FAIR TORT CLAIM FORM
Physical Injury or Death from Incident on August 13, 2011
OAG Form: 795549/Rev.
SECTION 5: Payment – Choose preferred method of payment
RETURN COMPLETED FORM by mail to:
STATE FAIR TORT CLAIM ADMINISTRATOR
C/O JWF Specialty
Attn: Heather Hunter
600 E. 96th Street, Suite 425
Indianapolis, IN 46240
Materials provided in response to the request to provide patient medical records and financial records will be maintained confidentially and are not accessible by the public through the Access to Public Records Act based on the provisions of Indiana Code §
SECTION
Upon verification of claimed loss, a payment may be made based on established protocol from the Indiana Tort Claim Fund. Please provide information below for the administrator to determine payment dispersal as warranted.
Account Number
Routing Number
Social Security Number
Account Type: Checking
Money Market
Savings
Other
Financial Institution
Name of Bank Contact if Known (Optional)
Address |
City |
State |
Zip |
Telephone Number Main
Fax Number
Other Telephone
SECTION
I request a waiver from electronic transfer requirements. Please mail check made payable to:
Name: |
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Social Security Number: |
Address:
City, State, Zip:
Claimant
Parent, Guardian or Representative
Claimant Name: |
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