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Claim for Damages Form

2. This Form Submits Directly to the City Clerk.

4. CLAIMANT INFORMATION

6. Claimant Name*

7. Date of Birth*

9. Current Residential Address

11. Address*

13. City*

14. State*

15. Zip Code*

17. Mailing Address if Different

19. Address

21. City

22. State

23. Zip Code

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

27. Address

29. City

30. State

31. Zip Code

33. Claimant's Daytime Phone Number*

34. Claimant's Email Address*

36. INCIDENT INFORMATION

38. Date of Incident*

39. Time of Incident*

40. Time*

    1. AM
    2. PM

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

44. FROM

45. TO

47. Location of Incident*

49. Name, Addresses and Telephone Numbers of All Persons Involved In, Or Witness To This Incident.*

51. Name of All City of Stanwood Employees Having Knowledge of This Incident. N/A in Not Applicable.*

53. 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.

55. Describe the Cause of the Injury or Damages. Explain the Extent of the Property Loss, or Medical, Physical, or Mental Injuries.*

57. Has the Incident Been Reported to Law Enforcement? If Yes, List Agency and Name of Officer (if known).*

59. Have You Filed a Claim With Your Insurance Carrier? If Yes, List Insurance Carrier Name, Phone Number, and Claim Number.*

61. 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.

63. Documentation

64. Documentation

65. Documentation

66. Documentation

68. ADDITIONAL INFORMATION REQUIRED FOR AUTOMOBILE CLAIMS

70. Vehicle Year / Make / Model

71. License Plate Number

73. Driver Name, Address, and Phone Number

75. Vehicle Owner Name, Address, and Phone Number

77. I am Claiming Damages in the Amount of :*

79. 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.

81. 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.

    1. I agree.
83. Electronic Signature*

84. Date & Time*
    Date & Time

    Date & Time

Leave This Blank:


86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit

* indicates a required field