Fillable Claim For Damages Form Web (City of Sumner)

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Claim For Damages Form Web (City of Sumner)

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PRESENTATION OF A CLAIM INSTRUCTIONS
This City of Sumner Claim for Damages form must be signed, and the form with original signature (not
a photocopy or scanned copy) must be mailed or delivered to:
Mail to: Deliver to:
City Clerk’s Office Sumner City Hall
1104 Maple Street Attn: City Clerk
Sumner, WA 98390 1104 Maple Street
Sumner, WA 98390
8:00am-5:00pm M-F
Upon receipt of your complete claim form, the City and/or its insurer will begin processing and reviewing
the matter in order to determine an appropriate resolution. It is to your advantage to present with your
claim along with relevant supporting documents (receipts, cancelled checks, estimates, billings, etc.) or
additional evidence (photos, diagrams, etc.). Please note that the claim form and other supporting
documents filed with the City Clerk are considered public records under the Revised Code of Washington
Chapter 42.56, the Public Records Act. Public records are presumed subject to disclosure upon request.
If you have any questions about filing, please contact Michelle Converse, City Clerk, during normal
business hours Monday-Friday 8:00 am – 5:00 pm. Please also see Sumner Resolution 1190 and RCW
4.96.020 for more information regarding the claim filing process.
CLAIM FOR DAMAGES FORM
MEMBER CITY/ORGANIZATION: City of Sumner
Please take note that , who currently resides at ,
___________________ mailing address _________________________________________,
home phone # , work phone #
, and who resided at
at the time of the occurrence and whose date of birth is is
claiming damages against in the sum of $ arising out of the following
circumstances listed below.
DATE OF OCCURRENCE: _________________________
TIME: _______________
LOCATION OF OCCURRENCE: _______________________________________________________
DESCRIPTION:
1. Describe the conduct and circumstance that brought about the injury or damage. Describe the injury or damage.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
________________________________________________(attach an extra sheet for additional information, if needed)
2. Provide a list of witnesses, if applicable, to the occurrence including names, addresses, and phone numbers.
______________________________________________________________________________________________
______________________________________________________________________________________________
3. Attach copies of all documentation relating to expenses, injuries, losses, and/or estimates for repair.
4. Have you submitted a claim for damages to your insurance company? ☐Yes ☐No
If so, please provide the name of the insurance company: and the policy #: ____________
ADDITIONAL INFORMATION REQUIRED FOR AUTOMOBILE CLAIMS ONLY
License Plate # ____________________________
Driver License # ______________________
Type Auto: Year: ___________ Make:_____________ Model:_____________________________
DRIVER: __________________________________
Address: __________________________________
__________________________________
Phone# __________________________________
Passengers:
Name: __________________________________
Address: __________________________________
__________________________________
OWNER: __________________________________
Address: __________________________________
__________________________________
Phone# __________________________________
Name: __________________________________
Address: __________________________________
__________________________________
NOTE: THIS FORM MUST BE SIGNED AND NOTARIZED
I,
, being first duly sworn, depose and say that I am the claimant for the above
described; that I have read the above claim, know the contents thereof and believe the same to be true.
X_________________________________________
X_________________________________________
Signature of Claimant(s)
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.
Signature: ____________________________________________
Dated: ______________________
Title: _______________________________________________ My appointment expires ________________
Date Claim Form Received by Member: ______________
CLAIM FOR DAMAGES FORM
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Claim For Damages Form Web (City of Sumner)

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Completed 25 July 2020

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