Mail Completed Form to:
City of Olympia - Claims Manager
PO Box 1967
Olympia WA 98507-1967
Office: (360) 753-8451
City Hall: 601 4th Ave E
CLAIM FOR DAMAGES FORM
MEMBER CITY: OLYMPIA
Date Claim Form
Received by Member
__________________________
CLAIMANT INFORMATION
Name Date of Birth
St Address @ Time of Loss Home Phone
Current St Address (if different) Work Phone
Mailing Address (include zip) Cell Phone
The above listed claimant is claiming damages against the City of Olympia arising out of the circumstances described below.
CLAIM INFORMATION
Attach copies of all documentation relating to expenses, injuries, losses and/or estimates for repair.
Date of Loss Claim Amount
Incident Location Time of Loss
Description
(Describe the conduct
and circumstances
that brought about
the damage or injury
AND describe the
damage or injury)
Witnesses (If
applicable, provide a
list of witnesses,
including name,
address and contact
phone number)
Have you submitted a claim to your insurance company? Select if YES Policy No.
AUTOMOBILE INFORMATION (Only complete this portion for vehicle damage)
License Plate No. Year/Make/Model
Vehicle Owner Information Vehicle Driver Information (if not owner)
Owner Name Driver Name
Driver License No. Driver License No.
Address Address
City/State/Zip City/State/Zip
Contact Phone Contact Phone
Passenger Name(s) Passenger Name(s)
** THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY **
I swear or affirm under penalty of perjury that I am the claimant for the above described loss; that I have read the above claim, know the contents
thereof, and believe the same to be true.
Claimant Signature
PRINT Name as Signed
State of Washington
County of ______________________________________
I certify that I know or have satisfactory evidence that _______________________________________________________________________ is the person who appeared
before me, and said person acknowledged that he/she signed this instrument and acknowledged it to be his/her free and voluntary act for the uses
and purposes mentioned in the instrument.
Date ___________________________________________
Notary Signature ___________________________________________
Title ___________________________________________
My Appointment Expires __________________________________________
