SF95-07a - Claim for Damage, Injury, or Death Form

Q: What information must be provided in the basis of the claim section?

Describe the known facts and circumstances, identify persons and property involved, state the place of occurrence, and explain the cause of the incident. Additional pages can be used if needed.

Q: How should property damage and personal injury amounts be reported?

Enter amounts in the specified items for property damage, personal injury, wrongful death, and the total. Failure to specify may cause forfeiture of rights.

Q: What insurance details does the form request?

It asks whether the claimant carries accident insurance and, if applicable, the insurer name, address, and policy number. It also asks about prior claims with the insurance carrier and whether the claimant carries public liability and property damage insurance.

Sep 16, 2026

Uploaded by Bill Black

SF95-07a is a claim form used to report and support requests for compensation involving property damage, personal injury, wrongful death, and related amounts. It collects claimant and representative identifying details, employment type, birth and marital status, date and time of the accident, and a detailed basis of the claim including persons, property, location, and cause. It also requests witness information, insurance coverage, claim amounts by category, certification and signatures, and warns about consequences for fraudulent claims.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Claimant and Instructions

Submission Information

Claim Details and Accident Information

Basis of Claim and Property Damage

Personal Injury / Wrongful Death

Witnesses and Claim Amounts

Certification, Signature, and Penalties

Insurance Coverage Questions

| CLAIM FOR DAMAGE,
INJURY,OR DEATH | | INSTRUCTIONS:Please read carefully the instructions on the
reverse side and supply information requested on both sides of this
form.Use additional sheet(s)if necessary.See reverse side for
additional instructions. | | | | FORM APPROVED
OMB NO.1105-0008 | | | --- | --- | --- | --- | --- | --- | --- | --- | | 1.Submit to Appropriate Federal Agency: | | | | 2.Name,address of claimant,and claimant's personal representative if any.
(See instructions on reverse).Number,Street,City,State and Zip code. | | | | | 3.TYPE OF EMPLOYMENT
□MILITARY
□CIVILIAN | 4.DATE OF BIRTH | 5.MARITAL STATUS | | 6.DATE AND DAY OF ACCIDENT | | 7.TME(A.M.OR P.M.) | | | 8.BASIS OF CLAIM (State in detailthe known facts and circumstances attending the damage,injury,or death,identifying persons and property involved,the place of occurrence and
the cause thereof.Use additional pages if necessary). | | | | | | | | | PROPERTY DAMAGE
9. | | | | | | | | | NAMEAND ADDRESS OF OWNER,IF OTHER THAN CLAIMANT(Number,Street,City,State,and Zip Code). | | | | | | | | | BRIEFLY DESCRIBE THE PROPERTY,NATURE AND EXTENT OF THE DAMAGEAND THELOCATION OFWHERE THEPROPERTY MAY BEINSPECTED.
(See instructions on reverse side). | | | | | | | | | 10.
PERSONAL INJURYWRONGFUL DEATH | | | | | | | | | STATE THE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF DEATH,WHICH FORMS THE BASIS OF THE CLAIM.IF OTHER THAN CLAIMANT,STATE THE NAME
OF THEINJURED PERSON OR DECEDENT | | | | | | | | | WITNESSES
11. | | | | | | | | | NAME | | ADDRESS(Number,Street,City,State,and Zip Code) | | | | | | | | | | | | | | | | AMOUNT OF CLAIM(in dollars)
12.(See instructions on reverse). | | | | | | | | | 12a.PROPERTY DAMAGE | 12b.PERSONAL INJURY | | 12c.WRONGFULDEATH | | 12d.TOTAL(Failure to specify may cause
forfeiture of your rights). | | | | I CERTIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURIES CAUSED BY THE INCIDENT ABOVE AND AGREE TO ACCEPT SAID AMOUNT IN
FULL SATISFACTION AND FINAL SETTLEMENT OF THIS CLAIM. | | | | | | | | | 13a.SIGNATURE OF CLAIMANT (See instructions on reverse side). | | | | 13b.PHONE NUMBER OF PERSON SIGNING FORM | | | 14.DATE OF SIGNATURE | | CIVIL PENALTY FOR PRESENTING
FRAUDULENT CLAIM
The claimantisliable to the United States Government for a civil penalty of not less than
s5000 and not more than $10,000,plus 3 times the amount of damages sustained
by the Government.(See 31 U.S.C.3729) | | | | CRIMINAL PENALTY FOR PRESENTING FRAUDULENT
CLAIM OR MAKING FALSE STATEMENTS
Fine,imprisonmentor both.(See 18U.S.C.287,1001.) | | | | | INSURANCE COVERAGE | | | | --- | --- | --- | | In order that subrogation claims may be adjudicated,it is ssenta that th claimant provide the flowing informafon regarding th isurance coverage of he vehicle or propery. | | | | 15.Do you carry accident Insurance? Yes If yes,give name and address of insurance company (Number,Street,City,State,and Zip Code)and policy number.□No | | | | 16.Have you filed a claim with your insurance carrier in this instance,and ifso,is it full coverage or deductible?
□No
Yes | | 17.If deductible,state amount. | | 18.If a claim has been filed with your carrier,what action has your insurer taken or proposed to take with reference to your claim?(It is necessary that you ascertain these facts). | | | | □Yes If yes,give name and address of insurance carrier (Number,Street,City,State,and Zip Code).
19.Do you carry publc liability and property damage insurance?L
□No | | | | INSTR
Claims presented under the Federal Tort Claims Act should be su
employee(s)was involved in the incident.If the incident involves
clam form.
Complete all items-Insert th <

FAQs

What information must be provided in the basis of the claim section?

Describe the known facts and circumstances, identify persons and property involved, state the place of occurrence, and explain the cause of the incident. Additional pages can be used if needed.

How should property damage and personal injury amounts be reported?

Enter amounts in the specified items for property damage, personal injury, wrongful death, and the total. Failure to specify may cause forfeiture of rights.

What insurance details does the form request?

It asks whether the claimant carries accident insurance and, if applicable, the insurer name, address, and policy number. It also asks about prior claims with the insurance carrier and whether the claimant carries public liability and property damage insurance.

Sep 16, 2026

Uploaded by Bill Black