Claim For Damages Form - City Of Auburn printable pdf download

CLAIM FOR DAMAGES FORM

Date Claim Form

Received by Member

____________

MEMBER CITY/ORGANIZATION

CITY OF AUBURN

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 the City of Auburn in the sum of

$________________ arising out of the following circumstances listed below.

DATE OF OCCURRENCE: ________________________________

TIME: ________________________

LOCATION OF OCCURRENCE: ________________________________________________________________________________

DESCRIPTION:

Describe the conduct and circumstance that brought about the injury or damage. Also describe the injury or damage

___________________________________________________________________________________________________________

____________________________________________________________ (attach an extra sheet for additional information, if needed)

Provide a list of witnesses, if applicable, to the occurrence including names, addresses, and phone numbers.

___________________________________________________________________________________________________________

Attach copies of all documentation relating to expenses, injuries, losses, and/or estimates for repair.

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_________________________________________

Signature of Claimant(s)

State of Washington, County of ______________

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.

Dated: ______________________

_______________________________________________

Signature

_______________________________________________

Title

My appointment expires ________________

Claim For Damages Form - City Of Auburn

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