Claim For Damages Form - City Of Sumner

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Date Claim Form Received by Member: ______________
CLAIM FOR DAMAGES FORM
MEMBER CITY/ORGANIZATION
City of Sumner
:
Please take note that
, who currently resides at
,
___________________ mailing address _________________________________________,
home phone #
, work phone #
, and who resided at
at the time of the occurrence and whose date of birth is
is
claiming damages against
in the sum of $
arising out of the following
circumstances listed below.
DATE OF OCCURRENCE: _________________________
TIME: _______________
LOCATION OF OCCURRENCE: _______________________________________________________
DESCRIPTION:
1.
Describe the conduct and circumstance that brought about the injury or damage. Describe the injury or damage.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
________________________________________________(attach an extra sheet for additional information, if needed)
2.
Provide a list of witnesses, if applicable, to the occurrence including names, addresses, and phone numbers.
______________________________________________________________________________________________
______________________________________________________________________________________________
3.
Attach copies of all documentation relating to expenses, injuries, losses, and/or estimates for repair.
4.
Have you submitted a claim for damages to your insurance company? ☐Yes
☐No
If so, please provide the name of the insurance company:
and the policy #: ____________
ADDITIONAL INFORMATION REQUIRED FOR AUTOMOBILE CLAIMS ONLY
License Plate # ____________________________
Driver License # ______________________
Type Auto: Year: ___________
Make:_____________ Model:_____________________________
DRIVER: __________________________________
OWNER: __________________________________
Address: __________________________________
Address: __________________________________
__________________________________
__________________________________
Phone# __________________________________
Phone# __________________________________
Passengers:
Name: __________________________________
Name: __________________________________
Address: __________________________________
Address: __________________________________
__________________________________
__________________________________
NOTE: THIS FORM MUST BE SIGNED AND NOTARIZED
I,
, being first duly sworn, depose and say that I am the claimant for the above
described; that I have read the above claim, know the contents thereof and believe the same to be true.
X_________________________________________
State of Washington
County of ______________
X_________________________________________
Signature of Claimant(s)
I certify that I know or have satisfactory evidence that ________________________ is the person who
appeared before me, and said person acknowledged that (he/she) signed this instrument and acknowledged it to be
(his/her) free and voluntary act for the uses and purposes mentioned in the instrument.
Signature: ____________________________________________
Dated: ______________________
Title: _______________________________________________
My appointment expires ________________

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