Who needs a Standard Form 95?
This Standard Form 95, Claim for Damage, Injury, or Death, is to be used by a Federal agency employee suffering from some accident to provide all known information about the damage, injury, or death, identifying persons and property involved, the place of occurrence, and the cause of the accident.
What is the Standard Form 95 for?
Information provided on this form will be used by the appropriate Federal agency whose employee was involved in the accident to assign a possible payment of compensation the amount of which depends on each specific case.
The amount claimed should be substantiated by competent evidence.
Is the Standard Form 95 accompanied by other forms?
For different cases in which this form should be filed, a submitter must present the following supporting documents:
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Written report by the attending physician;
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Two itemized signed statements or estimates by reliable or the itemized signed receipts evidencing payment (in case of property damage);
How do I fill out the Standard Form 95?
A submitter should read carefully the instructions on the second page and supply information requested on both pages of this form.
The following information must be provided in order to complete the form:
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The name and address of the appropriate Federal agency;
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Claimant’s personal information and address;
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Type of employment;
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Date of birth;
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Marital status;
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Date and day of the accident;
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Time of the accident;
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Basis of the claim;
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Information on property damage (if any);
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Information on personal injury or wrongful death (if any);
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Information on the witnesses;
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Amount of claim.
To be completed, this claim form must be signed and dated. Telephone number of person signing the form must be provided as well.
Where do I send Standard Form 95?
Once completed and signed, this form should be directed to the appropriate Federal agency responsible for satisfying compensation to their employees who suffered the accident.
