Fill - Free fillable Claim for Damages Packet (City Of Sunnyside) PDF form

Return To:

City of Sunnyside

City Clerk’s Office

818 E. Edison Avenue

Sunnyside, WA 98944

Phone: 509-836-6310

Claim for Damages Packet

If you have sustained injury or your property damaged and you believe the City of Sunnyside to be responsible,

you may submit a Claim for Damages form to the City Clerk’s Office at 818 E. Edison Avenue, Sunnyside, WA

98944. Please read all of the information contained in the packet prior to completing and submitting your Claim

for Damages.

Documents Contained in the Packet:

 Instructions for Completing the Standard Tort Claim Form

 Standard Tort Claim Form

Legal Requirements for Submitting a Claim Form

In order to verify the claim and additional supporting information, the law requires that the Standard Tort Claim

form be signed by:

 Claimant; or

 Person holding a written power of attorney from the Claimant; or

 Attorney in fact for the Claimant; or

 Attorney admitted to practice in Washington State on the Claimant’s behalf; or

 A court-approved guardian or guardian ad litem on behalf of the Claimant

Important

 Submitting a claim for damages does not guarantee payment by the City. An investigation will be made to

determine if the City has liability. If it is determined that the City has responsibility for the injury or

damage, the amount of any payment will be based on the level of your liability (if any), and the

depreciated value (not replacement value) of any property damaged.

 Investigations of claims for damages are typically conducted by City personnel, Washington Cities

Insurance Authority personnel or claims adjusters employed by Evergreen Adjustment Services, Inc. The

length of the investigation varies greatly depending on the complexity of the issues and the availability of

evidence to support the claim. All relevant information and documents should be provided for

consideration.

 If you have contacted the City in an emergency, as a public service, the Public Works crew or other City

employees may have assisted you in minor clean-up. This assistance does not constitute an admission of

liability on the part of the City.

 The completed form may be subject to public disclosure.

Present in Person or Mail the Claim Form and Supporting Documents to:

City of Sunnyside - City Clerk’s Office

818 E. Edison Avenue

Sunnyside, WA 98944

Phone: 509-836-6310

For further information you may contact Human Resource Department 509-836-6388

Business Hours: Monday-Friday 8:00am to 5:00pm

Closed on weekends and Major Holidays

Return To:

City of Sunnyside

City Clerk’s Office

818 E. Edison Avenue

Sunnyside, WA 98944

Phone: 509-836-6310

Instructions for Completing a Standard Tort Claim Form

 Type or print clearly in ink and sign the Form. State Law requires an original signature on the form which

means that they cannot be submitted electronically (by fax or email). While not required by law, we ask

that the form be notarized which can be accomplished at our office at the time of submission.

 Provide all requested information and any available documents or evidence supporting your claim such as

damage estimates, receipts, bills, photographs, etc

 If requested information cannot be supplied in the space provided, please use additional blank sheets.

 The following are examples on how to complete the Standard Tort Claim Form:

 If the incident that caused the damages occurred over a period of time, please provide the

beginning time and ending time.

 Provide the dollar amount for your damages that should represent your opinion of total

compensation.

 Location should be specific (example): 234 S. 1st. Street, Sunnyside, WA.

 Please describe the incident that you are claiming damages for specifically answering the

questions: who, what, where, when and why.

 List all witnesses having knowledge of the incident in question with their names, addresses and

phone numbers.

 If the incident was reported to law enforcement please provide a copy of the report or the

contact information for the report.

 If you are claiming damages to an automobile please complete information regarding the driver

and owner of the vehicle as well as any passengers.

 If a claim has been submitted to your insurance carrier please provide their information.

Mail or Deliver to:

Office Hours:

Home Phone:

Work Phone:

State of Washington

County of Yakima

SUBSCRIBED AND SWORN to before me this ______day of________________, 20_______

Date Filed at City Clerk's Office: Date to WCIA / Department / HR Risk Mngt:

Incident Location or Street Intersection:

Residential Address:

Mailing Address: (if Different)

Residential Address at the Time of the Incident: (If Different)

Name:

Birthdate:

CLAIM FOR DAMAGES FORM

City Clerk's Office, 818 E. Edison Avenue, Sunnyside, WA 98944 Phone: (509) 836-6310

Monday - Friday 8:00 a.m. - 5:00 p.m. (Except Holidays)

All items of information must be completed in full in order to assure prompt review

of your claim. See reverse side for additional instructions and necessary

information.

Signature of Claimant - (MUST BE SIGNED IN PRESENCE OF A NOTARY)

Amount Claimed:

Incident Date & Time:

Notary Public in and for the State of WA

Accurately describe the circumstances in which the incident occurred. Please include a description of the

damage or injury. Attach an additional sheet if necessary. See the reverse side of this form for additional

required information regarding automobile claims.

Has incident been reported to any City personnel? If yes, when and to whom?

Name, address and phone no. of any persons involved in or witness to this incident:

I, ___________________________________, being duly sworn on oath depose and say that the above claim

information is true and correct; that I am the sole owner or person entitled to reimbursement for damages and

that I executed the same as my free act and deed.

click to sign

signature

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PLEASE COMPLETE:

SECTION I.

SECTION II.

FOR PROPERTY DAMAGE CLAIMS

FOR AUTOMOBILE DAMAGE CLAIMS

ATTACH COPIES OF ALL DOCUMENTS IN SUPPORT OF YOUR CLAIM FOR EXPENSES

I. PROPERTY DAMAGE

Have you submitted a claim for damages to your insurance company? □ Yes □ No

ITEM DAMAGED:

DATE

ACQUIRED:

COST OF

REPAIR OR

CLEANING:

AMOUNT CLAIMED:

Owner Insurance Co. and Policy No.:

Type of Auto: (Year) (Make & Model) (License Plate No.)

Do you have estimates or copies of bills attached?

II. AUTOMOBILE CLAIMS - ADDITIONAL INFORMATION REQUIRED

Has this incident been reported to law enforcement, safety or security personnel? If yes, when and to whom?

REGISTERED OWNER INFORMATION

Name :

Name:

Name of Driver:

Registered Owner Name:

Registered Owner Phone No.:

Have you submitted a claim for damages to your insurance company? □ Yes □ No

Owner Insurance Co. and Policy No.:

DRIVER INFORMATION

Address:

Phone No.:

Driver Address:

Driver Phone No.:

PASSENGER ONE INFORMATION

PASSENGER TWO INFORMATION

Registered Owner Address:

Driver License No:

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