Thurston County Claim For Damages Form - 2013 printable pdf download

FOR OFFICE USE ONLY

CLAIM FOR DAMAGES

CLAIM #

Review Instructions Prior to Completing this Form

PLEASE TYPE OR PRINT IN INK

__________________

Pursuant to Chapter 4.96 RCW, this form is for filing tort claims for damages against Thurston County. Some of the

information requested on this form is required by RCW 4.96.020 and may be subject to public disclosure. You must submit a

claim against Thurston County using this form or the “Standard Tort Claim” form available from Washington State Office of

Financial Management (OFM) available on-line at Claims cannot be submitted

electronically (via e-mail or fax).

The signed original Claim for Damages against Thurston County must be presented in person or mailed to the

Thurston County Risk Manager. The Risk Manager is located in the Human Resources Office.

MAILING ADDRESS:

OFFICE LOCATION:

Thurston County Human Resources

Risk Management Division

2000 Lakeridge Drive SW

929 Lakeridge Drive SW, Room 202

Olympia, WA 98502

OFFICE BUSINESS HOURS: Monday – Friday 9:00 a.m. – 4:00 p.m.

CLOSED ON WEEKENDS AND HOLIDAYS

OFFICE TELEPHONE NUMBER: (360) 786-5498

1) NAME OF CLAIMANT: ___________________________________________________ 2) BIRTH DATE:______________

Last Name

First

Middle

3) CURRENT RESIDENTIAL ADDRESS: ______________________________________________________________

Street

Apt #

City

State

Zip

4) CURRENT MAILING ADDRESS IF DIFFERENT: ______________________________________________________

Street and/or PO Box

Apt #

City

State

Zip

5) RESIDENTIAL ADDRESS AT TIME OF INCIDENT (If different from current address):________________________

________________________________________________________________________________________________

6) TELEPHONE: (include Area Code)

________________________________ EMAIL: ____________________

Home

________________________________

Work

________________________________

Cell

7) DATE OF INCIDENT: _____________________8) TIME OF INCIDENT: _____________________am pm_____

(mm/dd/yyyy)

9) IF THE INCIDENT OCCURRED OVER A PERIOD OF TIME, DATE OF FIRST AND LAST OCCURRENCES:

FROM_________________ Time:_______ am pm

TO:________________ Time:___________ am pm

(mm/dd/yyyy)

10) LOCATION OF INCIDENT: _______________________________________________________________________

Address

City, Building or Office if applicable

11) LOCATION IF THE INCIDENT OCCURRED ON A STREET OR

If your vehicle is involved:

HIGHWAY:

Year:

_____________________

Make:

_____________________

Name of Street or Highway, Milepost Number,

Model:

_____________________

Color:

_____________________

At the intersection with/or nearest cross street

License #:

_____________________

Registered Owner:

Revised 7/2013

Thurston County Claim For Damages Form - 2013

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