126. Every claim for compensation shall be in writing, signed by the claimant or a person legally authorized to act on behalf of the claimant, and set out the following information:

the name of the inmate or person on day parole in respect of whom the claim is made;

in the case of a claim for a disability,

the date of the incident giving rise to the claim, and

the nature and location of any medical care provided to the inmate or person on day parole; and

in the case of a claim in respect of the death of an inmate or a person on day parole, the names and addresses of all known dependents.