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Claim for Damages Form

  1. Memo: Claim for Damages

    Please be advised that the mere presence of City staff is not an admission of liability. We are present to investigate a situation which has been reported to us. If you or your property has been damaged and, in your opinion, you believe the City may have a responsibility to you; a Claim for Damages Form can be obtained from the City Clerk’s office at City Hall. Some homeowners may find it useful to contact their own insurance company. Many homeowner insurance policies provide broader coverage for property damage than provided under the City’s insurance coverage. Submittal of a Claim for Damages does not guarantee payment by the City or its insurance carrier. An investigation by a claims adjuster will be made into the incident to determine if the City has any liability. Please excuse the number of possible interruptions during the investigation period. If it is determined that the City has a responsibility to you, the amount of claim payment is based on the level of City liability, the level of your liability (if any), the amount of repairs or value of the property that was damaged. If you contacted the City in an emergency, as a public service, City employees may have assisted you in minor clean up. Remember this assistance does not constitute an admission of liability on the part of the City. Should you have further questions about filing a claim, please contact Pat Adams at 360-454-5221.

  2. CLAIMANT INFORMATION

  3. Current Residential Address

  4. Mailing Address if Different

  5. Residential Address AT TIME OF INCIDENT (if different from current address).

  6. INCIDENT INFORMATION

  7. Time*

  8. If the Incident Occurred Over a Period of Time, Date of First and Last Occurrences

  9. Please Include a Brief Description as to the Nature and Extent of Each Person's Knowledge.

  10. Please Attach Any Other Documentation That You Believe Supports your Claim.

  11. ADDITIONAL INFORMATION REQUIRED FOR AUTOMOBILE CLAIMS

  12. 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 Washing State on the Claimant's Behalf, or by a Court-Approved Guardian, or Guardian Ad Litem on Behalf of the Claimant.

  13. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

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  15. This field is not part of the form submission.