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CITY OF EVERETT Instructions for Completing a Tort Claim Form • Before filing a Tort Claim, please read these instructions and then complete the Tort Claim Form and other appropriate forms in their entirety. • Type or print clearly in ink and sign the Tort Claim Form. • Provide all requested information and any available documents or evidence supporting your claim, such as medical records or bills for personal injuries, photographs, proof of ownership for property damages, receipts for property value, etc. • If the requested information cannot be supplied in the space provided, please use additional blank sheets so your claim can be easily read and understood. • The following are examples on how to complete the Tort Claim Form. 1. Smith, Karen Michelle, 02/02/1975 2. 1234 College Way NW, Apt. 56, Everett WA 98201 3. PO Box 910, Everett WA 98206 4. Same (or residence at the time of incident) 5. (425) 123-4567 6. [EMAIL REDACTED] NOTE: Please print email address clearly as most communication will be sent via email. Please check your Junk email periodically. 7. 08/08/2008, 8:00 am/pm 8. If the incident that caused the damages occurred over a period of time, please provide the beginning date and time and the ending date and time. 9. Washington, Snohomish, Everett, South Police Precinct 10. Evergreen Way northbound near 41st Street 11. If the incident involves a vehicle accident/collision, please provide the requested information relating to your vehicle. 12. Smith, Thomas Arthur, 1234 Everett Avenue, Everett WA 98201 (425) 456-3456 13. If known 14. List all other witnesses having knowledge of the incident in question, with their names, addresses, and telephone numbers that are not listed within items 12 and 13. Also include a description of their knowledge, e.g. if your sister was with you when the incident occurred, please include her name, address, telephone number, and indicate she witnessed the incident. 15. Describe the incident that resulted in the injury or damages, specifically answering the questions who, what, where, when and why. 16. If you reported this incident to law enforcement, safety, or security personnel, please provide a copy of the report or the contact information for the person with whom you spoke. 17. If you were treated for a personal injury, provide all of your medical providers’ names, addresses, telephone numbers, and the type of treatment. Include your medical records and bills and sign and attach a Medical Release form. 18. Supporting documents 19. Provide the dollar amount for your damages, including your time loss, medical costs, property damage loss, etc. This amount should represent your opinion of the total compensation you are claiming. ---PAGE BREAK--- Rev. 03/19 TORT CLAIM FORM PLEASE TYPE OR PRINT CLEARLY IN INK City Clerk’s Office City of Everett 2930 Wetmore Ave., Ste. 1-A Everett, WA 98201 Mail or deliver original signed claim form to: Business Hours: Mon – Thurs, 8 a.m. to 5 p.m. (Closed: 12 p.m. to 1 p.m. for lunch and city holidays) CLAIMANT INFORMATION: 1. Claimant’s name: Last name First Middle Date of birth 2. Current residential address: 3. Mailing address (if different): 4. Residential address at the time of the incident (if different from current address): 5. Claimant’s telephone number: Home Cell Business 6. Claimant’s e-mail address: INCIDENT INFORMATION: 7. Date of incident: Time : a.m. p.m. (check one) (mm/dd/yyyy) 8. If the incident occurred over a period of time, date of first and last occurrences: from: Time: a.m. p.m. (check one) to Time: a.m. p.m. (check one) (mm/dd/yyyy) (mm/dd/yyyy) 9. Location of incident: State and county City, if applicable Place where occurred 10. If the incident occurred on a street or highway: Name of street or highway At the intersection with or nearest intersecting street Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), this form is for filing a tort claim against the City of Everett. Some of the information requested on this form is required by RCW 4.96.020 and may be subject to public disclosure. The City Clerk is the City’s designated agent for the purpose of receiving claims. Claim forms cannot be submitted electronically (via email or fax). City of Everett Use Only City Clerk Claim No. ---PAGE BREAK--- Rev. 03/19 11. If this claim involves a vehicle accident/collision, provide your vehicle information: Plate No. Make Model Year Driver’s Name Driver’s License No. Vehicle Owner(s) (if different from driver) Owner’s Insurance Company Phone No. Policy No. 12. Names, addresses and telephone numbers of all persons involved in or witness to this incident: 13. Names, addresses and telephone numbers of all City of Everett employees having knowledge about this incident: 14. Names, addresses and telephone numbers of all individuals not already identified in #12 and #13 above who have knowledge regarding the liability 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. 15. Describe the cause of the injury or damages. Explain the extent of property loss or medical, physical or mental injuries. Attach additional sheets if necessary. 16. Has this incident been reported to law enforcement, safety or security personnel? If so, when and to whom? 17. Names, addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. 18. Please attach documents that support the claim’s allegations. 19. I claim damages from the City of Everett in the sum of This claim form must be signed by either the Claimant or on behalf of the Claimant by an attorney-in-fact who holds a written power of attorney for the Claimant, or by an attorney at law admitted to practice in the State of Washington, or by a court-approved guardian or guardian ad litem. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Signature of Claimant Date Place signed (city and state)