Should a private citizen incur personal injury, death or damage to property, as provided in the Good Samaritan Act, the private citizen or a person dependent upon such citizen for principal support may file a claim in the office of the Governor for indemnification to the extent that the claimant is not compensated from any other source for such injury, death or damage. The claim shall state:

1. l. The date, place and circumstances which gave rise to the claim;
2. 2. A general description of the activities of the private citizen during the event;
3. 3. The estimated extent of the injury, death or damage sustained for which the claimant is not compensated from any other source; and

4. 4. Such other information as the office of the Governor may require.

   The claim shall be accompanied by a corroborating statement.

Laws 1980, HB 1721, c. 344, § 2, eff. October 1, 1980.