GSA Form SF-95 "Claim for Damage, Injury, or Death"

GSA Form STANDARD95 is a U.S. General Services Administration form also known as the "Claim For Damage, Injury, Or Death". The latest edition of the form was released in February 1, 2007 and is available for digital filing.

Download a PDF version of the GSA Form STANDARD95 down below or find it on U.S. General Services Administration Forms website.

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Download GSA Form SF-95 "Claim for Damage, Injury, or Death"

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INSTRUCTIONS:
CLAIM FOR DAMAGE,
FORM APPROVED
Please read carefully the instructions on the
OMB NO. 1105-0008
reverse side and supply information requested on both sides of this
INJURY, OR DEATH
form. Use additional sheet(s) if necessary. See reverse side for
additional instructions.
1. Submit to Appropriate Federal Agency:
2. Name, address of claimant, and claimant's personal representative if any.
(See instructions on reverse). Number, Street, City, State and Zip code.
3. TYPE OF EMPLOYMENT
4. DATE OF BIRTH
5. MARITAL STATUS
6. DATE AND DAY OF ACCIDENT
7. TIME (A.M. OR P.M.)
MILITARY
CIVILIAN
8. BASIS OF CLAIM (State in detail the known facts and circumstances attending the damage, injury, or death, identifying persons and property involved, the place of occurrence and
the cause thereof. Use additional pages if necessary).
PROPERTY DAMAGE
9.
NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT (Number, Street, City, State, and Zip Code).
BRIEFLY DESCRIBE THE PROPERTY, NATURE AND EXTENT OF THE DAMAGE AND THE LOCATION OF WHERE THE PROPERTY MAY BE INSPECTED.
(See instructions on reverse side).
PERSONAL INJURY/WRONGFUL DEATH
10.
STATE THE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF DEATH, WHICH FORMS THE BASIS OF THE CLAIM. IF OTHER THAN CLAIMANT, STATE THE NAME
OF THE INJURED PERSON OR DECEDENT.
WITNESSES
11.
NAME
ADDRESS (Number, Street, City, State, and Zip Code)
12. (See instructions on reverse).
AMOUNT OF CLAIM (in dollars)
12a. PROPERTY DAMAGE
12b. PERSONAL INJURY
12c. WRONGFUL DEATH
12d. TOTAL (Failure to specify may cause
forfeiture of your rights).
I CERTIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURIES CAUSED BY THE INCIDENT ABOVE AND AGREE TO ACCEPT SAID AMOUNT IN
FULL SATISFACTION AND FINAL SETTLEMENT OF THIS CLAIM.
13a. SIGNATURE OF CLAIMANT (See instructions on reverse side).
13b. PHONE NUMBER OF PERSON SIGNING FORM 14. DATE OF SIGNATURE
CIVIL PENALTY FOR PRESENTING
CRIMINAL PENALTY FOR PRESENTING FRAUDULENT
FRAUDULENT CLAIM
CLAIM OR MAKING FALSE STATEMENTS
The claimant is liable to the United States Government for a civil penalty of not less than
Fine, imprisonment, or both. (See 18 U.S.C. 287, 1001.)
$5,000 and not more than $10,000, plus 3 times the amount of damages sustained
by the Government. (See 31 U.S.C. 3729).
NSN 7540-00-634-4046
STANDARD FORM 95 (REV. 2/2007)
Authorized for Local Reproduction
PRESCRIBED BY DEPT. OF JUSTICE
Previous Edition is not Usable
28 CFR 14.2
95-109
INSTRUCTIONS:
CLAIM FOR DAMAGE,
FORM APPROVED
Please read carefully the instructions on the
OMB NO. 1105-0008
reverse side and supply information requested on both sides of this
INJURY, OR DEATH
form. Use additional sheet(s) if necessary. See reverse side for
additional instructions.
1. Submit to Appropriate Federal Agency:
2. Name, address of claimant, and claimant's personal representative if any.
(See instructions on reverse). Number, Street, City, State and Zip code.
3. TYPE OF EMPLOYMENT
4. DATE OF BIRTH
5. MARITAL STATUS
6. DATE AND DAY OF ACCIDENT
7. TIME (A.M. OR P.M.)
MILITARY
CIVILIAN
8. BASIS OF CLAIM (State in detail the known facts and circumstances attending the damage, injury, or death, identifying persons and property involved, the place of occurrence and
the cause thereof. Use additional pages if necessary).
PROPERTY DAMAGE
9.
NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT (Number, Street, City, State, and Zip Code).
BRIEFLY DESCRIBE THE PROPERTY, NATURE AND EXTENT OF THE DAMAGE AND THE LOCATION OF WHERE THE PROPERTY MAY BE INSPECTED.
(See instructions on reverse side).
PERSONAL INJURY/WRONGFUL DEATH
10.
STATE THE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF DEATH, WHICH FORMS THE BASIS OF THE CLAIM. IF OTHER THAN CLAIMANT, STATE THE NAME
OF THE INJURED PERSON OR DECEDENT.
WITNESSES
11.
NAME
ADDRESS (Number, Street, City, State, and Zip Code)
12. (See instructions on reverse).
AMOUNT OF CLAIM (in dollars)
12a. PROPERTY DAMAGE
12b. PERSONAL INJURY
12c. WRONGFUL DEATH
12d. TOTAL (Failure to specify may cause
forfeiture of your rights).
I CERTIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURIES CAUSED BY THE INCIDENT ABOVE AND AGREE TO ACCEPT SAID AMOUNT IN
FULL SATISFACTION AND FINAL SETTLEMENT OF THIS CLAIM.
13a. SIGNATURE OF CLAIMANT (See instructions on reverse side).
13b. PHONE NUMBER OF PERSON SIGNING FORM 14. DATE OF SIGNATURE
CIVIL PENALTY FOR PRESENTING
CRIMINAL PENALTY FOR PRESENTING FRAUDULENT
FRAUDULENT CLAIM
CLAIM OR MAKING FALSE STATEMENTS
The claimant is liable to the United States Government for a civil penalty of not less than
Fine, imprisonment, or both. (See 18 U.S.C. 287, 1001.)
$5,000 and not more than $10,000, plus 3 times the amount of damages sustained
by the Government. (See 31 U.S.C. 3729).
NSN 7540-00-634-4046
STANDARD FORM 95 (REV. 2/2007)
Authorized for Local Reproduction
PRESCRIBED BY DEPT. OF JUSTICE
Previous Edition is not Usable
28 CFR 14.2
95-109
INSURANCE COVERAGE
In order that subrogation claims may be adjudicated, it is essential that the claimant provide the following information regarding the insurance coverage of the vehicle or property.
15. Do you carry accident Insurance?
Yes
If yes, give name and address of insurance company (Number, Street, City, State, and Zip Code) and policy number.
No
16. Have you filed a claim with your insurance carrier in this instance, and if so, is it full coverage or deductible?
Yes
No
17. If deductible, state amount.
18. If a claim has been filed with your carrier, what action has your insurer taken or proposed to take with reference to your claim? (It is necessary that you ascertain these facts).
19. Do you carry public liability and property damage insurance?
Yes
If yes, give name and address of insurance carrier (Number, Street, City, State, and Zip Code).
No
INSTRUCTIONS
Claims presented under the Federal Tort Claims Act should be submitted directly to the "appropriate Federal agency" whose
employee(s) was involved in the incident. If the incident involves more than one claimant, each claimant should submit a separate
claim form.
Complete all items - Insert the word NONE where applicable.
A CLAIM SHALL BE DEEMED TO HAVE BEEN PRESENTED WHEN A FEDERAL
DAMAGES IN A SUM CERTAIN FOR INJURY TO OR LOSS OF PROPERTY, PERSONAL
AGENCY RECEIVES FROM A CLAIMANT, HIS DULY AUTHORIZED AGENT, OR LEGAL
INJURY, OR DEATH ALLEGED TO HAVE OCCURRED BY REASON OF THE INCIDENT.
REPRESENTATIVE, AN EXECUTED STANDARD FORM 95 OR OTHER WRITTEN
THE CLAIM MUST BE PRESENTED TO THE APPROPRIATE FEDERAL AGENCY WITHIN
NOTIFICATION OF AN INCIDENT, ACCOMPANIED BY A CLAIM FOR MONEY
TWO YEARS AFTER THE CLAIM ACCRUES.
The amount claimed should be substantiated by competent evidence as follows:
Failure to completely execute this form or to supply the requested material within
two years from the date the claim accrued may render your claim invalid. A claim
(a) In support of the claim for personal injury or death, the claimant should submit a
is deemed presented when it is received by the appropriate agency, not when it is
mailed.
written report by the attending physician, showing the nature and extent of the injury, the
nature and extent of treatment, the degree of permanent disability, if any, the prognosis,
and the period of hospitalization, or incapacitation, attaching itemized bills for medical,
If instruction is needed in completing this form, the agency listed in item #1 on the reverse
hospital, or burial expenses actually incurred.
side may be contacted. Complete regulations pertaining to claims asserted under the
Federal Tort Claims Act can be found in Title 28, Code of Federal Regulations, Part 14.
(b) In support of claims for damage to property, which has been or can be economically
Many agencies have published supplementing regulations. If more than one agency is
repaired, the claimant should submit at least two itemized signed statements or estimates
involved, please state each agency.
by reliable, disinterested concerns, or, if payment has been made, the itemized signed
receipts evidencing payment.
The claim may be filled by a duly authorized agent or other legal representative, provided
evidence satisfactory to the Government is submitted with the claim establishing express
(c) In support of claims for damage to property which is not economically repairable, or if
authority to act for the claimant. A claim presented by an agent or legal representative
the property is lost or destroyed, the claimant should submit statements as to the original
must be presented in the name of the claimant. If the claim is signed by the agent or
cost of the property, the date of purchase, and the value of the property, both before and
legal representative, it must show the title or legal capacity of the person signing and be
after the accident. Such statements should be by disinterested competent persons,
accompanied by evidence of his/her authority to present a claim on behalf of the claimant
preferably reputable dealers or officials familiar with the type of property damaged, or by
as agent, executor, administrator, parent, guardian or other representative.
two or more competitive bidders, and should be certified as being just and correct.
If claimant intends to file for both personal injury and property damage, the amount for
(d) Failure to specify a sum certain will render your claim invalid and may result in
each must be shown in item number 12 of this form.
forfeiture of your rights.
PRIVACY ACT NOTICE
This Notice is provided in accordance with the Privacy Act, 5 U.S.C. 552a(e)(3), and
B. Principal Purpose: The information requested is to be used in evaluating claims.
concerns the information requested in the letter to which this Notice is attached.
C. Routine Use: See the Notices of Systems of Records for the agency to whom you are
submitting this form for this information.
A. Authority: The requested information is solicited pursuant to one or more of the
following: 5 U.S.C. 301, 28 U.S.C. 501 et seq., 28 U.S.C. 2671 et seq., 28 C.F.R.
D. Effect of Failure to Respond: Disclosure is voluntary. However, failure to supply the
requested information or to execute the form may render your claim "invalid."
Part 14.
PAPERWORK REDUCTION ACT NOTICE
This notice is solely for the purpose of the Paperwork Reduction Act, 44 U.S.C. 3501. Public reporting burden for this collection of information is estimated to average 6 hours per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Director, Torts
Branch, Attention: Paperwork Reduction Staff, Civil Division, U.S. Department of Justice, Washington, DC 20530 or to the Office of Management and Budget. Do not mail completed
form(s) to these addresses.
STANDARD FORM 95
BACK
REV. (2/2007)
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