Claim for Damages InstructionsrkW City of Port Orchard
!n: . ���_. 216 Prospect Street, Port Orchard, WA 98366
(360) 876-4407 • FAX (360) 895-9029
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TORT CLAIM FOR DAMAGES
Instructions
Before filing a Tort Claim, please read these instructions and the City's Tort Claim forms in their
entirety. Alternatively, you can use the standard Tort Claim form that is maintained by the risk
management division of the office of financial management for the State of Washington.
Instructions:
• Type or print clearly in ink and sign the Tort Claim form.
• The Tort Claim form must be signed either: (i) By the claimant, verifying the claim; (ii)
Pursuant to a written power of attorney, by the attorney in fact for the claimant; (iii) By an
attorney admitted to practice in Washington State on the claimant's behalf; or (iv) By a court -
approved guardian or guardian ad litem on behalf of the claimant.
• Provide all requested information and any available documents or evidence supporting your
claim, such as medical records or bills for personal injuries, photographs, proof of ownership for
property damages, receipts for property value, etc.
• If the requested information cannot be supplied in the space provided, please use additional
blank sheets so your claim can be easily read and understood.
The form must be returned with the attachments to:
City Clerk
City of Port Orchard
216 Prospect Street
Port Orchard, WA 98366
Monday — Friday (Excluding Holidays) 8:00 AM -4:30 PM
cityclerk@portorchardwa.gov
Once the completed and signed form is received, the City Clerk will review the claim and route
to the appropriate department for review in order to determine:
• Who is the responsible party,
• Whether to pay the claim,
• Forward the claim to the City's insurance agency (AWC/RMSA) for consideration, or
• Deny the claim.
The City Clerk or an AWC/RMSA employee will contact you if additional information is required
in order to evaluate the claim.
Should you have any questions regarding this form or the City's claims process, please contact
the City Clerk at (360) 876-7030.