Full Text
INSTRUCTIONS FOR COMPLETING AND FILING A CLAIM FOR DAMAGES PLEASE READ CAREFULLY! A City of Kennewick Claim for Damages form is enclosed. Please follow the steps listed below for faster processing of your claim. 1) Complete the claim form. Please provide as much detail as possible in the description section regarding the incident that you are claiming damages for. If requested information cannot be supplied in the space provided, please use additional blank sheets. 2) You must sign and date this official claim form. State law requires that the form be signed by the claimant, the claimant’s attorney (or attorney-in-fact as authorized by a written power of attorney), or a court-approved guardian or guardian-ad-litem on behalf of the claimant. State law requires an original signature on the Claim for Damages form; therefore, claim forms cannot be submitted by fax or email. 3) It is to your advantage to attach relevant supporting documents (copies of any receipts, bills, invoices, estimates) or additional evidence (photos, diagrams, and such). A claim can be resolved faster when all relevant information is provided for consideration. All documents are subject to the Washington State public disclosure statutes and will be released without advance notice to you. 4) You must file your claim with the City Clerk in order for it to be valid (KMC 1.32.015). In the absence of the City Clerk, the Executive Assistant/Deputy City Clerk is authorized to accept service. The City Clerk's Office is open Monday - Friday between 8:30 a.m. and 4:30 p.m. However, there are times the City Clerk and Executive Assistant/Deputy City Clerk are away from their desks. Therefore, it is recommended in-person visitors call ahead for an appointment. Please return the original, signed claim form and supporting documentation in person or via mail to: City of Kennewick Attn: Johnston, City Clerk In Person: 210 W 6th Ave; Kennewick (recommended to call ahead at [PHONE REDACTED]) By Mail: PO Box 6108; Kennewick, WA 99336 Once you file your claim with the City Clerk's Office, the Clerk will provide it to the Safety and Risk Management Coordinator who forwards the claim to Washington Cities Insurance Authority (WCIA). WCIA will assign the claim to an adjuster who will conduct an investigation that includes input from the involved City department. The length of the investigation varies greatly depending on the complexity of the issues and availability of evidence to support the claim. The adjuster will evaluate your claim and recommend a reasonable resolution, which will be one of three alternatives: 1) Accept/settle the claim; 2) Tender the claim (transfer it to another party); 3) Deny the claim (where there is no evidence of negligence by the City). Claim Questions?: If you have any questions regarding the enclosed claim form, or the status of a submitted claim, please contact the Safety & Risk Management Coordinator at [PHONE REDACTED]. The City Clerk cannot assist you with questions about the status of a claim. CITY OF KENNEWICK 210 W 6th Ave; Kennewick, WA 99336 • PO Box 6108; Kennewick, WA 99336 ---PAGE BREAK--- CLAIM FOR DAMAGES FORM This Box for City Clerk's Office Use Only Agency: CITY OF KENNEWICK Received By: 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 incident: Time: am/pm If the incident occurred over a period of time, date of first and last occurrences: From: To: • Location of incident (please be specific – if on a City road, include exact area, address, or nearest cross streets): • Name, address, and phone number of all persons involved in or witness to this incident: Name Address Phone ( ) - ( ) - ( ) - • Names of all City of Kennewick employees having knowledge of this incident: • Name, address, and phone number 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. Name Address Phone ( ) - ( ) - ( ) - ---PAGE BREAK--- • 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, please provide agency police report number name of officer (if known) • Have you filed a claim with your insurance carrier? If so, what is their name, claim number and phone number? Name Claim Number Phone ( ) - • Name, address and phone number of treating medical provider(s). Please attach bills and records, if available. Name Address Phone ( ) - ( ) - • 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. Signature of Claimant REQUIRED: An original signature in ink. Do not add a digital signature. Do not submit a copy of a signature Date City Clerk's Date Stamp Parties shall personally serve the City Clerk or Deputy City Clerk at City Hall during official business hours pursuant to Revised Code of Washington (RCW) 4.28.080(2) and Kennewick Municipal Code (KMC) 1.28.010. Claim forms may also be mailed to the City Clerk: City of Kennewick Attn: Johnston, City Clerk PO Box 6108 Kennewick, WA 99336 Service upon any other person is not valid and will not be accepted as legal service.