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INSTRUCTIONS FOR COMPLETING AND FILING A CLAIM FOR DAMAGES PLEASE READ CAREFULLY! A City of Puyallup 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. While not required by law, we ask that the form be notarized which can be accomplished with no fee at our office at the time of claim submission. 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. 4) You must file your claim with the City Clerk in order for it to be valid. Return the original, signed claim form and supporting documentation in person or via mail to: City of Puyallup Attn: City Clerk Puyallup City Hall 333 S Meridian Puyallup, WA 98371 Once you file your claim with the City Clerk, the Clerk will log it in and provide a copy to the Risk & Safety 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). If you have any questions regarding the enclosed claim form, please contact the City’s Risk & Safety Coordinator at (253) 841-5594. CITY OF PUYALLUP Legal Department Claims•Risk Management•Safety 333 S Meridian•Puyallup, WA 98371 Phone (253)841-5594•Fax (253)770-3352 ---PAGE BREAK--- CLAIM FOR DAMAGES FORM For Official Use Only City/Organization: CITY OF PUYALLUP 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 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 Puyallup 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 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: SIGN SIGN