Understanding the power of outsourcing is key to achieving many businesses’ goals. The OAG Form 795549 (also known as the Application for Contractor Approval) serves a critical purpose for contractors looking to provide products and services in support of state or federal initiatives and projects. This form, created by the Alcohol and Tobacco Tax Regulator of Virginia, provides an important layer of oversight necessary for some companies’ success, keeping both consumers and industry stakeholders safe. Read below to learn more about how this form fits into today’s business environment, what it entails when it comes time to complete it accurately and efficiently, plus critical questions you should be asking before submitting your application package.
| 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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2. |
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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4. |
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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