Claim for Damages Form (Tort Form)

SPOKANE TRANSIT CLAIM FOR DAMAGES FORM

For injury or damages to persons or personal property
Personal Information
Claimant’s Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Residence/Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Daytime Phone number*
Home, cell and/or businessFormat: (000) 000-0000.
Email*
example@example.com
Incident Information
Date of Incident*

MonthDayYear
Date
Time of Incident*

Hour Minutes

AM/PM Option
Location of Incident*
Names, addresses and phone numbers of all persons involved, or witness, to this incident:*
Names and phone numbers of all Spokane Transit employees who have knowledge about this incident:*
Describe conduct and circumstances causing injury or damage, explaining extent of medical, physical or mental injuries:*
Name, address and phone number of treating medical provider(s):*
I/we do hereby claim damages from Organization* in the sum of $ Monetary Value .

To be determined (TBD) is appropriate if you do not have a damage estimate or have not completed medical treatment
CLAIMAINT, OR LEGAL GUARDIAN, MUST SIGN THIS CLAIM FORM
I certify or declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
Type my signatureDraw my signature
To sign this form, type your name below:*
Signature*

Clear
Today's date*

MonthDayYear
Date
Address, City & County*
e.g. Spokane, Spokane County
If the claimant is incapacitated from verifying, presenting, and filing the claim or if the claimant is a minor, or is a nonresident of this state, the claim may be verified, presented, and filed on behalf of the claimant by any relative, attorney, or agent representing the claimant.

All claims for damages against Washington State Transit Insurance Pool Members arising out of tortuous conduct shall be presented to and filed with the appropriate transit company.
Should be Empty:

SPOKANE TRANSIT CLAIM FOR DAMAGES FORM

Personal Information

Incident Information

CLAIMAINT, OR LEGAL GUARDIAN, MUST SIGN THIS CLAIM FORM