The URL can be used to link to this page

Home My WebLink AboutN-352 - Claims for Damages Against City Return To: City of Pasco City Clerk’s Office 525 N 3rd Ave PO Box 293 Pasco WA 99301 Ph: 509-544-3096 Claim for Damages 1/4 7/2014 Claim for Damages Packet If you have sustained injury or your property damaged and you believe the City of Pasco to be responsible, you may submit a Claim for Damages form to the City Clerk’s Office at 525 N 3rd Ave, Pasco WA 99301. 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 Pasco - City Clerk’s Office 525 N 3rd Avenue Pasco WA 99301 Phone: 509-544-3096 For further information you may contact Human Resource Department 509-545-3408 Business Hours: Monday-Friday 8:00am to 5:00pm Closed on weekends and Major Holidays Return To: City of Pasco City Clerk’s Office 525 N 3rd Ave PO Box 293 Pasco WA 99301 Ph: 509-544-3096 Claim for Damages 2/4 7/2014 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.  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): 525 N 3rd Avenue, Pasco 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.  If a claim has been submitted to your insurance carrier please provide their information. Return To: City of Pasco City Clerk’s Office 525 N 3rd Ave PO Box 293 Pasco WA 99301 Ph: 509-544-3096 Claim for Damages 3/4 7/2014 Claim for Damages Form Date Received from Claimant 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. Return To: City of Pasco City Clerk’s Office 525 N 3rd Ave PO Box 293 Pasco WA 99301 Ph: 509-544-3096 Claim for Damages 4/4 7/2014 Describe the cause of the injury or damages. Explain the extent of the property loss or medical, physical or mental injuries. 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 of Claimant Date (If notarized, for notary to complete) 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. Dated: Signature: Title: My appointment expires: