GPA Claims Form - Georgia Ports Authority

NOTICE OF CLAIM AGAINST THE GEORGIA PORTS AUTHORITY

Instructions:

Claims against the Authority for property damage only that are less than $5,000 and do not involve bodily injury may be filed directly with the Authority as follows:
Georgia Ports Authority
Attn. Risk Management Department
PO BOX 2406
Savannah, GA 31402
Phone: 912-966-7803
Fax: 912-966-3609
Email: claims@gaports.com
This form is not purported to satisfy the requirements of the Georgia Tort Claims Act (§O.C.G.A. 50-21-26).
Any claim not meeting the above criteria must comply with all provisions of the Georgia Tort Claims Act (§O.C.G.A. 50-21-26).
All claims against the Authority shall be filed within 12 months of the date the loss was discovered or should have been discovered.
The Authority does not waive any rights it may have under any defenses, including sovereign or governmental immunity.
The following information must be completed in its entirety and provided along with any and all documentation necessary to prove your loss:

a. The acts or omissions of which are asserted as the basis of the claim:

b. The date the transaction or occurrence from which the alleged loss arose:

c. The place of the transaction or occurrence of which the alleged loss arose:

d.The nature of the alleged loss suffered:

e. The amount of loss claimed:

f. The acts or omissions which caused the alleged loss:

g. Was a GPA Port Police report filed relative to the alleged loss? YesNo
If yes, indicate the report number:
or date of report:

h. If applicable, identify (in detail) any involved equipment:

i. Describe in detail why you believe the Authority is responsible for the alleged loss:

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Contact Information of Person Filing Claim:

First Name: (required)

Last Name: (required)

Job Title: (required)

Company: (required)

Address 1: (required)

Address 2:

City: (required)

State: (required)

Zip Code: (required)

Phone Number: (required)

Fax Number:

Email Address: (required)