Government code 910: Fill out & sign online

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Click ‘Get Form’ to open the 910 claim form in the editor.
Begin by entering your name in the 'NAME OF CLAIMANT' field. Ensure that this matches your official identification.
Fill in your 'POST OFFICE ADDRESS' and the address where you want notices sent. This is crucial for communication regarding your claim.
Indicate the 'DATE OF INJURY, DAMAGE, LOSS OR OBLIGATION' accurately to establish a timeline for your claim.
Describe the location of the incident in detail under 'LOCATION WHERE THE INJURY, DAMAGE, LOSS OR OBLIGATION OCCURRED'.
Provide a thorough description of the injury or damage in the designated section. Attach additional pages if necessary.
List any public employees involved and describe their actions that led to your claim.
Include witness information, if available, as this can support your case.
Finally, calculate and enter the total amount of your claim and provide a breakdown of expenses in the relevant sections.

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What is a 910 claim?

Standard Form 95. Standard Form 95 is used to present claims against the United States under the Federal Tort Claims Act (FTCA) for property damage, personal injury, or death allegedly caused by a federal employees negligence or wrongful act or omission occurring within the scope of the employees federal employment.

What is a claim form?

The UB92 form (CMS-1450) is a standardized billing form used by healthcare providers to submit insurance claims for inpatient and outpatient hospital services, as well as for some other types of medical services. It was used in the United States from the 1980s until 2007 when the UB04 form replaced it.