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Claim Form Instructions
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Claimant Name, Address and Phone.  Please provide your complete contact information, along with a daytime phone number. 

State Agency Claim is Against.  If you do not know what state agency your claim is against, please contact the Claims Board for assistance. 

Statement of Circumstances.  Please provide a detailed statement explaining your claim.  The Claims Board is independent of other state agencies and does not have access to information that you may have already given to the state agency involved in your claim.  Because the Claims Board members will be unfamiliar with the history of your claim, you will need to provide complete background information about your claim, how it arose, and why you feel you should be compensated for your damages. 

Please attach additional pages, as necessary and include any relevant documents supporting your claim such as medical reports, police reports, or previous correspondence with the involved state agency.

Dollar Amount of Claim.  Please indicate the exact, total dollar amount of your damages. When calculating your damages, please bear in mind that the Claims Board has a long standing history of reimbursing claimants only for actual, out-of-pocket damages.  The board does not make awards for "intangible" damages such as inconvenience or pain and suffering. 

Submit copies of documents showing proof of the amount of damage you are claiming (bills, repair estimates, receipts, etc.).  The current statutory limit on the amount of money the Claims Board may award is $10,000.  Awards larger than $10,000 must be passed into law by the Wisconsin Legislature after recommendation of payment by the Claims Board.

Insurance Information.  Provide complete insurance information regardless of whether or not you have already filed or intend to file a claim with your insurance company.  (If your claim is not related to injury or property/vehicle loss or damage, and insurance therefore does not apply, you may leave this section blank.)

Signature & Notarization.  Your claim form must be signed and notarized. 

 

 

 

 


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Last Modified:  8/2/2011 10:40:02 AM
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