[Code of Federal Regulations]

[Title 33, Volume 1]

[Revised as of July 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 33CFR25.113]



[Page 96]

 

                TITLE 33--NAVIGATION AND NAVIGABLE WATERS

 

         CHAPTER I--COAST GUARD, DEPARTMENT OF HOMELAND SECURITY

 

PART 25_CLAIMS--Table of Contents

 

                            Subpart A_General

 

Sec. 25.113  Contents of claim.



    (a) A claim under the Federal Tort Claims Act must be presented 

using Standard Form 95, Claim for Damage, Injury, or Death.

    (b) A claim under any other Act may be presented using Standard Form 

95. Any claim which is not presented using Standard Form 95 shall 

include:

    (1) The identity of the department, agency, or activity whose act or 

omission gave rise to the claim;

    (2) The full name and mailing address of the claimant. If this 

mailing address is not claimant's residence, the claimant shall also 

include residence address;

    (3) The date, time, and place of the incident giving rise to the 

claim;

    (4) The amount claimed, supported by independent evidence of 

property damage or loss, personal injury, or death, as applicable;

    (5) A detailed description of the incident giving rise to the claim;

    (6) A description of any property damage or loss, including the 

identity of the owner, if other than the claimant, as applicable;

    (7) The nature and extent of the injury, as applicable;

    (8) The full name, title, if any, and address of any witness to the 

incident and a brief statement of the witness' knowledge of the 

incident;

    (9) A description of any insurance carried by the claimant or owner 

of the property and the status of any insurance claim arising from the 

incident; and

    (10) An agreement by the claimant to accept the total amount claimed 

in full satisfaction and final settlement of the claim.

    (c) A claimant or duly authorized agent or legal representative must 

sign in ink a claim and any amendment to that claim. If the person's 

signature does not include the first name, middle initial, if any, and 

surname, that information must be included in the claim. A married woman 

must sign her claim in her given name, e.g., ``Mary A. Doe,'' rather 

than ``Mrs. John Doe.''