Cite as [A.S.A.C. § 43.0105]
All claims are required to present in writing the circumstances of the incident(s), including, but not limited to, date, time, place, names and addresses of parties involved, names and addresses of witnesses, and a statement of the alleged negligent or wrongful act or omission of the government employee while acting within the scope of his or her office or employment. In addition to that information, the following evidence and information shall be submitted when presented pursuant to 43.0103 A.S.C.A:
(a) Death: In support of a claim based on death, the claimant shall be required to submit the following evidence or information:
(1) An authenticated death certificate or other competent evidence showing cause of death, date of death, and age of the decedent.
(2) Decedent’s employment or occupation at time of death, including his monthly or yearly salary or earnings, if any, and the duration of decedent’s last employment or occupation.
(3) Full names, addresses, birth dates, kinship, and marital status of the decedent’s survivors, including identification of those survivors who were dependent for support upon the decedent at the time of his death.
(4) Degree of support afforded by the decedent to each survivor dependent upon him for support at the time of death.
(5) Decedent’s general physical and mental condition before death.
(6) Itemized bills for medical and burial expenses incurred by reason of the incident causing death, or itemized receipts of payment for such expenses.
(7) If damages for pain and suffering prior to death are claimed, a physician’s detailed statement specifying the injuries suffered, duration of pain and suffering, any drugs administered for pain, and the decedent’s physical condition in the interval between injury and death.
(8) Any other evidence or information which may have a bearing on either the responsibility of the American Samoa Government for the death or the damages claimed.
(b) Personal Injury. In support of a claim for personal injury, including pain and suffering, the claimant shall be required to submit the following evidence or information:
(1) A written report by his attending physician or dentist setting forth the nature and extent of the injury, nature and extent of treatment, any degree of temporary or permanent disability, the prognosis, period of hospitalization, and any diminished earning capacity. In addition, the claimant may be required to submit to a physical or mental examination by a physician employed by the American Samoa Government. A copy of the report of the examining physician shall be made available to the claimant upon the claimant’s written request, provided that he has, upon request, furnished the report referred to in the first sentence of this subparagraph and has made or agrees to make available to the American Samoa Government any other physician’s reports previously or thereafter made of the physical or mental condition which is the subject matter of his claim.
(2) Itemized bills for medical, dental, and hospital expenses incurred, or itemized receipts or payment for such expenses.
(3) If the prognosis reveals the necessity for future treatment, a statement of expected expenses for such treatments.
(4) If a claim is made for loss of time from employment a written statement from his employer showing actual time lost from employment, whether he is a full or part-time employee, and wages or salary actually lost.
(5) If a claim is made for loss of income and the claimant is self-employed, documentary evidence showing the amounts of earnings actually lost.
(6) Any other evidence or information which may have a bearing on either the responsibility of the American Samoa Government for the personal injury or the damages claimed.
(c) Property Damage. In support of a claim for injury to or loss of property, real or personal, the claimant shall be required to submit the following evidence or information:
(1) Proof of ownership;
(2) A detailed statement of the amount claimed with respect to each item of property;
(3) An itemized receipt of payment for necessary repairs or itemized written estimates of the cost of such repairs;
(4) A statement listing date of purchase, purchase price and salvage value, where repair is not economical;
(5) Any other evidence or information which may have a bearing on either the responsibility of the American Samoa Government for the injury to or loss of property or the damages claimed.History: Rule 4-85. eff 30 Dec 85.