Free DT1725 - Wisconsin

STATE TRUNK HIGHWAY FIRE CALL CLAIM
DT1725 2/2003 (Replaces BAA81)

Wisconsin Department of Transportation

Town, Village, or City Clerk Pursuant to sections 60.557(2), 61.65(8), and 62.13(8) Wisconsin Statutes, a fire call claim may be made to the Department of Transportation for a fire or other qualifying event on a state trunk highway or other highways maintained by the Department. Fires which occur on a connecting street in a city or village that receives connecting highway aid are not eligible for reimbursement. The municipality should submit a written statement (e.g., letter to responsible party) to show it has made a reasonable effort to collect the cost from the person to whom the service was rendered. The Department of Transportation shall reimburse the municipality up to $500 for the costs, even if the fire equipment is not actually used. When fire equipment is called out as a matter of local policy whenever an emergency call is received and a qualifying event does not occur, the costs are not eligible for reimbursement. Claims and supporting documentation must be submitted within one year of the qualifying event to be eligible for payment. * The claim must be filed by the municipality in which the fire occurred. * Submit only one claim for each incident regardless of the number of vehicles or fires involved. * If reimbursement for the fire call has not been made by a company or individual, please complete this claim, attest to it by signing, and submit it to:
Wisconsin Department of Transportation Bureau of Financial Services P.O. Box 7366 Madison, WI 53707-7366
Town, Village, City (where fire occurred) Name(s) and Address(es) of Owners of Vehicles County Taxpayer Identification Number Amount of Claim Vehicle License Number Date of Fire Vehicle Insured by Location of Fire. Be specific. State Highway Number and distance from Village, City or Intersection Time of Call Type of Fire. What burned? Cause of Fire-Accident, etc.

Check this box if this is not a connecting street which receives connecting highway aid.

Fire Department Servicing Call and Equipment Responding

Check ONE of the following

Check this box if equipment was not used.

Volunteer Fire Department Salaried Fire Department Volunteer and Salaried Fire Department
What attempt was made to collect from parties involved? Attach documentation.

Purpose of Fire Call

Extinguish Fire Handle Gasoline/Hazardous Materials Extricate Victims
Indicate to whom payment shall be made (Town, Village or City Treasurer) Name Address

Cost of Fire to Municipality (Annual Fee Standard Cost Per Fire, Hourly Rate) or Cost of Wages and Supplies

I certify that the above claim is true and correct; no portion thereof has been or will be paid by another. I also certify that a reasonable effort has been made to collect from the person responsible for the event.
Must be signed by Clerk or municipality in which fire occurred or the claim will be returned.

X
(Town, Village or City Clerk) (Date) Please see other side.

INFORMATION ON FIRE CALLS PROGRAM

1.

Claims and supporting documentation must be submitted within one year of the qualifying incident to be eligible for payment. Clerks should provide evidence of attempts to collect payment. Evidence shall include copies of letters to responsible individuals/ insurance companies requesting payment. If possible, copies of written refusal to pay should also be included. By statute, payment will be made to city/village/town only, not to the fire department. The claim must be signed by the town/village/city clerk, not a fire official or other party. For all types of municipal government, payment shall be made for qualifying incidents even if the fire equipment is not actually used. Events which qualify for reimbursement when within the right-of way of an eligible route include: a. b. c. Responding to extinguish a fire on a vehicle, structure or vegetation; Responding to handle gasoline or other hazardous materials; Responding to a request for extrication equipment to remove or attempt to remove individuals trapped in vehicles as the result of a crash on an eligible highway.

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When fire equipment is called out as a matter of local policy whenever an emergency call is received and a qualifying event does not occur, the costs are not eligible for reimbursement. 7. Fire calls on county roads (unless the county road is part of a marked detour from an eligible route) should be billed to the proper county per State Statute 60.557(1). By statute, local governments in Wisconsin, except those villages with paid fire departments, or cities with solely paid or solely volunteer departments, are eligible to receive reimbursement for their actual expenses up to $500 per qualifying event. This means that a town served by any type of fire department, a village served by a volunteer fire department, or a city served by a combination of a paid and volunteer fire department is eligible for payment. No other type of fire department for each respective type of municipality is eligible for payment. Events on railroad tracks or property are not eligible. Payments are for fire equipment responses for the three eligible events, not for ambulance equipment responses.

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Wisconsin Department of Transportation
www.dot.wisconsin.gov

Bureau of Financial Services 4802 Sheboygan Ave. P O Box 7366 Madison, WI 53707-7366

To: From: Subject:

Municipalities Providing Fire Service on State Highways Cynthia Morehouse, Bureau of Financial Services Eligibility and Process for Submitting Fire Claims

Program Purpose Wisconsin law provides a mechanism for local governments to recover all or a portion of their costs for responding to fire calls on highways that are maintained by the state. This mechanism is intended to provide relief for those situations when fire services are required on the state highway right-of-way and the local government that is responsible for providing the service is unable to recover the costs of that service from the persons receiving the service, or when the responsible party is unknown. Eligibility Local governments in Wisconsin, except those villages with paid fire departments, or cities with solely paid or solely volunteer fire departments, are eligible to receive reimbursement for their actual expenses in responding to calls for emergency fire services on highways under the jurisdiction of the state of Wisconsin. Those highways include all state trunk highways, US highways, and the Interstate system (or marked detours from these routes) unless the highway is a connecting highway under the maintenance responsibility of a city or village. Events which qualify for reimbursement when within the right-of-way of an eligible route include: 1. 2. 3. Responding to extinguish a fire on a vehicle, structure or vegetation; Responding to handle gasoline or other hazardous materials; Responding to a request for extrication equipment to remove or attempt to remove individuals trapped in vehicles as the result of a crash on an eligible highway.

Actual costs, up to the maximum of $500 per qualifying event, may be reimbursed when fire equipment responds to any of these events for the purpose intended even though the fire equipment was not actually used. However, when fire equipment is called out as a matter of local policy whenever an emergency call is received and a qualifying event does not occur, the costs are not eligible for reimbursement. Actual expenses eligible for reimbursement must be reduced by any recovery of costs from, or on behalf of, the person to whom the services are provided. All local governments must make a good faith attempt to recover the costs for these emergency services from the individuals or insurance carriers involved in the event. Recoveries made through those efforts must be subtracted from the amount submitted for reimbursement. When the local government recovers the cost from the responsible party after the department reimburses the local government, the local government shall return the amount collected to the department. To Request Reimbursement Please complete the attached form (DT1725) for reimbursement of fire claims. Each claim should include a written statement that a reasonable effort has been made to collect the cost from or on behalf of the person to whom the service was provided before any payment can be made. Bills and supporting documentation must be submitted within one year of the qualifying incident to be eligible for payment. If you have questions about completing the form, please contact Mary Johnson at 608-267-3143. Should you have questions about the program requirements, please contact the program manager, Richard Moss, Bureau of Highway Operations, at 608-267-7830.