Box 13a. Signature of Claimant. The consumer-claimant or his/her legal representative signs here. 13b. Phone Number of Signatory. The consumer-claimant or his/her legal representative puts his phone number here.
FTCA Claim Form SF-95 Box 14
Box 14. Date of Signature (of Claimant or Claimant's legal representative). The consumer-claimant or his/her legal representative puts the date of his SF-95 here.
FTCA Claim Form SF-95 Box 15
Box 15. Do you carry accident insurance? The consumer-claimant states yes or no here. If yes, insert the name and address of insurance company and the insurance policy number.
FTCA Claim Form SF-95 Box 16
Box 16. Have you filed claim on your insurance carrier in this instance, and if so, is it full coverage or deductible? The consumer-claimant states whether or not he or she has filed an insurance claim and whether or not the coverage is full or has a deductible.
FTCA Claim Form SF-95 Box 17
Box 17. If deductible, state amount. The consumer-claimant inserts the dollar amount of the insurance deductible, if applicable.
FTCA Claim Form SF-95 Box 18
Box 18. If claim has been filed with your carrier, what action has your insurer taken or proposes to take with reference to your claim? The consumer-claimant states here the action his or her insurance company has take or proposed with respect to any filed claim.
FTCA Claim Form SF-95 Box 19
Box 19. Do you carry public liability and property damage insurance? The consumer-claimant states here whether or not he or she has carries public liability and property damage insurance, and, if so, inserts the name and address of insurance company.
Present the Completed SF-95 to the Appropriate Federal Government Agency
Once the SF-95 is completed, the form must be "presented" to, or filed with, the appropriate federal agency in order to comply with the requirements of administrative exhaustion under the Federal Tort Claims Act. The date the federal agency receives the completed SF95 form is considered the date of presentation for calculating the statute of limitations under the FTCA. Consumer-claimants should get a receipt of delivery by registered or certified mail, or overnight express, in order to verify a timely presentation of the administrative tort claim.
Consult with a Lawyer Should You Have any Questions about the FTCA
Complying with the requirements of the Federal Tort Claims Act can be technical and sometimes confusing. Should the consumer be unsure of whether or not his or her administrative claim will be in compliance with the provisions of the FTCA, a lawyer with FTCA experience should be consulted. A(C) Joseph P. Griffith, Jr. 2010
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