Lane County Risk Management Damage Claim Form

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LANE COUNTY
RISK MANAGEMENT
DAMAGE CLAIM FORM
Claimant’s Name:
Date Reported:
Mailing Address:
City, State, Zip:
Phone:
E-Mail:
Describe Incident/Damages:
1. Date of incident:
Time:
AM
PM
2. Type of incident:
Collision
Pothole
Rock
Sanding/Resurfacing
(attach copy of DMV report)
Road Paint
white
yellow
Driver Side
Passenger Side
Other:
Why did you cross the line?
Other Damage
:
[describe]
3. Description of Claimant’s vehicle:
a. Year:
b. Make:
c. Model:
d. Color:
e. License Plate State/Number:
f. Registered Owner:
4. Describe the Lane County vehicle, if any, that caused the damage:
a. Year:
b. Make:
c. Color of vehicle:
d. License number:
e. Vehicle I.D. Number:
f. Type of vehicle (sedan, truck, mower, sander etc.):
5. Location of incident:
a. Highway name and/or number:
b. Milepost marker or landmark(s):
c. Direction and distance to nearest town:
6. Did the incident happen on a
Straight Roadway
Curve
7. Were there flashing lights or warning signs?
At what point did you see them?
(over)

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