Fillable Claim for Damages Packet Please read all of (City of Duvall)

Fill Online, Printable, Fillable, Blank Claim for Damages Packet Please read all of (City of Duvall) Form

Use Fill to complete blank online CITY OF DUVALL (WA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Claim for Damages Packet Please read all of (City of Duvall)

On average this form takes 9 minutes to complete

The Claim for Damages Packet Please read all of (City of Duvall) form is 4 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Duvall

BROWSE CITY OF DUVALL (WA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Claim for Damages
Packet
Please read all of the 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
•
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. Please note: The City of Duvall does not provide notary public service.
•
The length of the Claim for Damages 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.
•
The completed form may be subject to public disclosure.
Present in Person or Mail the Claim Form and Supporting Documents to:
City of Duvall
c/o City Clerk’s Office
15535 Main Street NE
PO Box 1300
Duvall, WA 98019
Phone: 425-788-1185
Business Hours: Monday-Friday 8:30am to 4:30pm (Closed on weekends and official holidays)
Instructions for Completing a Standard Tort Claim Form
•
Type or print clearly in ink and sign the Form
•
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 so your claims can be easily read and understood.
•
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 – examples: “123 Andover Park E” or
“intersection of 123
rd
Avenue NE and NE James Street”
•
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.
•
If a claim has been submitted to your insurance carrier please provide their information.
Received Stamp
City Clerk’s Office
15535 Main Street NE
PO Box 1300
Duvall, WA 98019
(425) 788-1185
www.duvallwa.gov
City of Duvall Claim for Damages Form
This form must be completed (clearly printed or typed) and submitted to the City Clerk. You may submit other documents
to support your claim including pictures, receipts, etc. For questions, please contact the City Clerk at (425) 788-1185.
Claim No.:
Received By:
Date Received:
Claimant Information
Claimant’s name: Date of Birth:
Current residential address:
Mailing address (if different):
Residential address at the time of the incident (if different from current address):
Claimant’s daytime phone number (work, home or cell)
Claimant’s email address:
Incident Information
Date of the incident: Time: am / pm
If the incident occurred over a period of time, date of first and last occurrences:
From: To:
Location of incident:
Name, addresses and telephone numbers of all persons involved in or witness to this incident:
Name of all of our employees having knowledge of this incident:
Name, addresses and telephone numbers of all individuals not already identified above that have knowledge regarding
the issues involved in this incident or knowledge of the claimant’s resulting damages. Please include a brief description
as to the nature and extent of each person’s knowledge. Attach additional sheets if necessary.
Describe the cause of the injury or damages. Explain the extent of the property loss or medical, physical or mental
injuries. Indicate why City of Duvall is responsible for this injury or damage. Attach additional sheets if necessary.
Has this incident been reported to law enforcement? If so, which agency and name of officer (if known).
Have you filed a claim with your insurance carrier? If so, what is their name, phone number and claim number?
Name address and telephone numbers of treating medical providers. Please attach billings and records if available.
Please attach any other documentation that you believe support your claim’s allegations.
*Additional Information Required for Automobile Claims Only*
License Plate # Year/ Make/ Model
Driver Name, Address & Phone
Owner Name, Address & Phone
Passenger(s) Name, Address & Phone
I am claiming damages in the amount of
I declare under penalty of perjury under the laws of the State of Washington the foregoing is true and correct. This
Claim form must be signed by the Claimant, a person holding a written power of attorney from the Claimant, by an
attorney admitted to practice in Washington State on the Claimant’s behalf or by a court-approved guardian or
guardian ad litem on behalf of the Claimant.
Signature:
Date:
(For notary to complete) Please note: The City of Duvall does not provide Notary Public service.
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.
Subscribed and sworn to before me this ___ day of ____________, 20_________.
Signature: _________________________________
Printed: ___________________________________
Notary Public in and for the State of Washington
Residing at: ________________________________
My appointment expires: ____________________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Claim for Damages Packet Please read all of (City of Duvall)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 November 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document