Get Limited Access Highway Incident Claim Form - Ct.gov

Filing a claim using the LIMITED ACCESS HIGHWAY INCIDENT CLAIM FORM is an important step for volunteer fire companies seeking reimbursement for incidents on limited access highways. This guide provides clear instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the claim form effectively.

1. Press the ‘Get Form’ button to obtain and open the claim form in your preferred editing tool.
2. Begin by filling out the 'Fire Company Name' and 'Telephone #' sections. Ensure that the name corresponds to the official name of your fire company.
3. In the 'Location' section, provide the address of the incident. If the mailing address differs from the location, fill in the 'Mailing Address' and specify whose address it is along with the reason for the difference.
4. Record the 'Date of Incident' and 'Time of Incident', and specify the 'Highway Involved' along with the precise 'Location' and 'City/Town'.
5. Indicate the type of incident by checking the appropriate boxes under 'What was reported', such as 'Single Vehicle Accident' or 'Structure Fire', and provide any additional descriptions if needed.
6. Fill in the 'Vehicle Identification' section by providing details such as year, make, model, color, license plate number, state, VIN number, and the number of occupants involved.
7. Answer whether the incident has been reported to the State Fire Marshal. If yes, enter the relevant FD ID# and Incident#.
8. Complete the certification section by having both the Fire Chief and Incident Commander sign. Each must provide their signature and the date.
9. Review the completed form for accuracy and completeness. Make sure all required fields are filled out properly.
10. Once the form is accurately filled out, save your changes, and then choose to download, print, or share the claim form as needed.

Complete the LIMITED ACCESS HIGHWAY INCIDENT CLAIM FORM online today to ensure your reimbursement is processed promptly.