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Claim for Damages Form
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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.
Date of Birth
Current Residential Address
Mailing Address if Different
Residential Address AT TIME OF INCIDENT (if different from current address).
Claimant's Daytime Phone Number
Claimant's Email Address
Date of Incident
Time of Incident
If the Incident Occurred Over a Period of Time, Date of First and Last Occurrences
Location of Incident
Name, Addresses and Telephone Numbers of All Persons Involved In, Or Witness To This Incident.
Name of All City of Stanwood Employees Having Knowledge of This Incident. N/A in Not Applicable.
Name, Address and Telephone 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.
Describe the Cause of the Injury or Damages. Explain the Extent of the Property Loss, or Medical, Physical, or Mental Injuries.
Has the Incident Been Reported to Law Enforcement? If Yes, List Agency and Name of Officer (if known).
Have You Filed a Claim With Your Insurance Carrier? If Yes, List Insurance Carrier Name, Phone Number, and Claim Number.
Name, Address, and Telephone Number of Treating Medical Provider. Please Attach Medical Bills and Records if Available.
Please Attach Any Other Documentation That You Believe Supports your Claim.
ADDITIONAL INFORMATION REQUIRED FOR AUTOMOBILE CLAIMS
Vehicle Year / Make / Model
License Plate Number
Driver Name, Address, and Phone Number
Vehicle Owner Name, Address, and Phone Number
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 Washing State on the Claimant's Behalf, or by a Court-Approved Guardian, or Guardian Ad Litem on Behalf of the Claimant.
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.
Date & Time
Date & Time
Date & Time
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