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Tort Claims

City of Linden

Please click here to view and/or download the City of Linden ordinance for tort claims against the City of Linden.

Tort Claim Form

This claim form must be filed within ninety (90) days of accident or occurrence or you may forfeit your rights pursuant to N.J.S.A. 59:8-1 et seq.

Claimant

Name(Required)
Address(Required)

Additional Correspondance

If notices and correspondence in connection with this claim are to be sent to a person other than claimant, please complete this section.
Name
Address
Should notices and correspondence in connection with this claim be sent to a person other than claimant?
MM slash DD slash YYYY
Please enter the date of the occurrence or accident that gave rise to this claim.
Time
:
Please enter the time of the occurrence or accident that gave rise to this claim.
Address
Please enter the address of the occurrence or accident that gave rise to this claim.
Describe how the accidence or occurrence happened. If a diagram will assist your explanation, you may upload a diagram below.
Drop files here or
Accepted file types: jpg, Max. file size: 200 MB.
    You may upload a diagram and/or any photos of the occurrence. The ONLY permitted file type for this upload is .jpg.
    If there were any Municipal Employees whom you claim were at fault, please identify them here, including any information that will assist in identifying and locating them.
    State in detail each and every negligent or wrongful act of the Municipality and Municipal employees who caused your damage(s).
    State the names and addresses of al witnesses to the accident or occurrence.
    State the names of all Police Officers who investigated the incident.
    If there is an associated police report associated with this claim, please enter it here.
    Damages
    Please check the appropriate box(es).
    Describe your injuries resulting from this accident or occurrence.
    Do you claim permanent disability resulting from this injury?
    Describe the injuries believed to be permanent.
    For each hospital, doctor, or other practitioner rendering treatment or diagnostic service, state the following information: (1) Name of Hospital/Doctor/Facility (2) Address (3) Dates of Treatment or Services (4) Amount of Charges to Date (5) Amount Paid or Payable by Other Sources Such As Insurance
    Have you had a loss or wages or income as a result of the injury?
    Please explain the following in your claim of loss of wages or income as a result of the injury? (1) Name of Employer(s) (2) Address of Employer(s) (3) Your Occupation & Title (4) Date of Initial Employment (5) Pay Rate (6) Dates of Absence from Work (7) Total Lost Wages to Date (8) Date of Return or Expected Date of Return
    Drop files here or
    Accepted file types: jpg, Max. file size: 200 MB.
      If your claimed loss of income arises from self-employment or other than wage, attach a calculation showing the basis of your calculation of lost income. Only the .jpg extension is available for this upload, so please take photos of your calculations and upload those photos here.
      Drop files here or
      Max. file size: 200 MB.
        Upload a photo in .jpg format of a letter from your employer verifying lost wages. If self-employed, then a statement showing the calculation of your claimed lost income.
        Set forth any and all other losses or damages claimed by you.
        Drop files here or
        Accepted file types: jpg, Max. file size: 200 MB.
          Make sure to upload copies (photos in .jpg format) of the following files. (1) Copies of itemized bills for each medical expense and other losses and expenses claimed. (2) Copies of all written reports of all expert witnesses and/or treating physicians.
          Set forth in detail the description of the property damage, the loss claimed by you for property damage, as well as all other items of loss of damages by you and the method by which you made the calculation(s).
          Property Location
          Please state the present location where the property can be inspected
          MM slash DD slash YYYY
          State the date when the property may be inspected.
          Property Inspection Time
          :
          State the time when the property may be inspected.
          MM slash DD slash YYYY
          State the date the property was acquired by you.
          Please state the cost of the property (what you paid) and the cost of the property at the time of the accident or occurrence.
          Has the damage been repaired?
          Please state who repaired the property; either an individual or company’s name.
          Drop files here or
          Max. file size: 200 MB.
            Please attach photos of all invoices and/or appraisals, and/or receipts of the estimates or actual cost to repair the damaged property from the accident or occurrence.
            The total amount of the claim for property damage.
            Have you made a claim against anyone else for any of the losses or expenses associated with this notice?
            Please describe in detail any claims against anyone else for any of the losses or expenses associated with this notice?
            Are any of the losses or expenses claimed herein covered by any insurance policy?
            For each such policy, state the names and addresses of the insurance company, policy number and benefits paid or payable.
            Have you received or agreed to receive any money from anyone for the damages claimed?
            Set forth the details of the agreement to receive any money from anyone for the damages claimed.
            Certification(Required)
            Please enter the name of the person certifying.
            Authorization to Collect Information
            Please enter the name of the person authorizing.

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