University Of Washington Claim Form printable pdf download

University of Washington Claim Form

In order to file a claim, return completed form to: Risk Services

Box 354964

Seattle, WA 98195

(206) 543-3657 Fax: (206) 543-6744

Website:

In the event that the claim cannot be resolved informally, filing this claim with the University of Washington

does not constitute a filing with the Department of Enterprise Services pursuant to RCW 4.92.110.

Claimant’s Name/Names (Person alleging damages): __________________________________________________

Claimant’s Date of Birth: ________________________________________________________________________

Claimant’s Home Telephone Number: ______________________________________________________________

Claimant’s Business Telephone Number: ____________________________________________________________

Claimant’s Email Address: _______________________________________________________________________

Mailing Address: ______________________________________________________________________________

_____________________________________________________________________________________________

Residence Address (if different): __________________________________________________________________

_____________________________________________________________________________________________

Department allegedly responsible for damage/injury: __________________________________________________

Total amount of damages claimed: ________________________________________________________________

Give itemization of damages for total amount claimed: _________________________________________________

_____________________________________________________________________________________________

Date of incident: ______________________________________________ Time: _________________________

Location of incident: ___________________________________________________________________________

_____________________________________________________________________________________________

University Of Washington Claim Form