Lane County Risk Management Damage Claim Form Page 2
Download a blank fillable Lane County Risk Management Damage Claim Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Lane County Risk Management Damage Claim Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
28. Describe the weather conditions:
9. What was your vehicle doing in relation to the other vehicle?
Passing
Following
Parked
Approaching from the opposite direction
Other (describe):
10. Direction and speed of vehicles:
a. Your vehicle direction:
Speed:
b. Other vehicle direction:
Speed:
c. Approximate distance between vehicles:
11. If your vehicle was damaged from rocks or debris, where did they come from: (road surface, tires of
vehicle, load, etc.):
12. Did you contact the vehicle driver?
Yes
No If known, please complete a, b, and c.
a. Driver’s Name:
b. Agency:
c. Work Phone:
13. Did you contact a County department?
Yes
No
If yes, which department and with whom did you speak? a. Dept:
b. Name:
c. Phone:
14. Were there witnesses to the incident?
Yes
No
In the vehicle with you?
Yes
No
a. Name:
b. Phone:
c. Address:
a. Name:
b. Phone:
c. Address:
15. Please provide one itemized, written estimate from a shop where you would be willing to have your
vehicle repaired if your claim is accepted for payment (if this is a claim for removing road striping
paint from your vehicle, please obtain your estimate from a detail shop).
16. Additional information:
Please return this form along with estimate and photographs of damage by mail, fax, or e-mail to:
LANE COUNTY RISK MANAGEMENT
LCRISKMG@co.lane.or.us
ATTN: Lisa Lacey
125 E. 8th Avenue
Fax: 541-682-4616
Eugene OR 97401
Submission of this form does not indicate Lane County has accepted liability for your claim;
your claim will be investigated and you will be contacted by mail or e-mail within two weeks.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal