SF95
Claim for Damage, Injury, or Death
Standard Form 95 (SF 95), Claim for Damage, Injury, or Death, is a claim form for damage to or loss of property, personal injury or death. The form is prescribed by the U.S. Department of Justice under 28 CFR 14.2, and GSA hosts a copy in its forms library. The form says claims under the Federal Tort Claims Act should be submitted directly to the appropriate federal agency whose employee was involved in the incident, which you name in item 1.
The form asks for the claimant's details, the facts of the incident, the property damage and injuries, witnesses, the amount claimed in dollars and insurance coverage. It says a claim must be presented to the appropriate federal agency within two years after the claim accrues, and that failure to specify a sum certain will render the claim invalid.
The Justice Department estimates an average of 6 hours per response. You can fill it out free in your browser on this page and download the result without an account.
The federal agency the claim goes to, the name and address of the claimant and any personal representative, military or civilian employment, date of birth, marital status, and the date, day and time of the accident.
The known facts and circumstances: the persons and property involved, the place it happened and the cause. Extra pages can be added.
The property owner if other than the claimant, the nature and extent of the damage and where the property can be inspected, then the nature and extent of each injury or the cause of death.
The name and address of each witness.
Dollar amounts for property damage, personal injury and wrongful death, and a total. The claimant certifies the amount covers only damages from the incident and agrees to accept it in full settlement, then signs and dates.
Accident insurance, any claim filed with your insurance carrier and its deductible, what your insurer has done about it, and public liability and property damage insurance.
Enter the federal agency whose employee was involved. If more than one agency is involved, the instructions say to state each one.
The form says to complete all items and insert the word NONE where applicable, and to use additional sheets if necessary.
Enter the amount for each type of claim and a total. The form says failure to specify a sum certain will render the claim invalid and may result in forfeiture of rights.
The instructions list a physician's written report and itemized bills for injury or death, and at least two itemized signed estimates or paid receipts for property that can be repaired.
The claimant signs item 13a. If an agent or legal representative signs, the form says it shows their title or legal capacity and comes with evidence of their authority.
Send the form to the agency named in item 1. The form says a claim is deemed presented when the agency receives it, not when it is mailed.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
Directly to the appropriate federal agency whose employee was involved. The form says not to mail completed forms to the Justice Department or OMB addresses in its burden notice.
The form says a claim must be presented to the appropriate federal agency within two years after it accrues, and is deemed presented when the agency receives it, not when it is mailed.
Statements of the original cost, date of purchase and value before and after the accident, by disinterested competent persons such as reputable dealers, certified as just and correct.
The form points to Title 28, Code of Federal Regulations, Part 14, and says many agencies have published supplementing regulations. The agency in item 1 may be contacted for help completing the form.
A civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the government's damages, for a fraudulent claim, and fine, imprisonment or both for fraudulent claims or false statements.
The instructions on the back of the form describe who presents the claim and how.
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The form says Federal Tort Claims Act claims should be submitted directly to the appropriate federal agency whose employee was involved in the incident. If more than one agency is involved, it says to state each one in item 1.
The form says a claim must be presented to the appropriate federal agency within two years after the claim accrues, and that a claim is deemed presented when the agency receives it, not when it is mailed.
The form says failure to specify a sum certain will render the claim invalid and may result in forfeiture of rights. For a claim covering both personal injury and property damage, it says to show the amount for each in item 12.
The form says a duly authorized agent or other legal representative may file it, with evidence of express authority to act for the claimant. The claim is presented in the claimant's name, and the signer's title or legal capacity is shown.
For injury or death, a written report by the attending physician and itemized medical, hospital or burial bills. For repairable property, at least two itemized signed estimates or paid receipts. For property that cannot be repaired, statements of its cost and value.
The form says that if the incident involves more than one claimant, each claimant should submit a separate claim form.
The form says the insurance information is needed so that subrogation claims may be adjudicated. Items 15 to 19 cover accident insurance, any claim with your carrier and its deductible, and liability insurance.
