Claim for Damage Form - King County Flood Control District

INSTRUCTIONS FOR COMPLETING THE CLAIM FOR DAMAGE FORM

Before filing a Claim for Damage please read these instructions and the Claim for Damage form in its entirety.

Type or print clearly in ink and sign the Claim for Damage form. If you are incapacitated, a minor or a non-resident of the state, a relative, attorney or agent may sign on your behalf.

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 attach additional documents in the File Upload section so your claim can be easily read and understood.

Records you submit are subject to public disclosure laws.
The following are examples on how to complete the Claim for Damage form:

(1) Doe, John Conner, 12/01/1910
(2) 222 One Way Street, Apt. Z, Seattle, Washington 98178
(3) Post Office Box 111, Seattle, Washington 98178
(4) Same
(5) (206) 555-5555
(6) 01/01/2009, 8:00 a.m.
(7) If the incident that caused the damages occurred over a period of time, please provide the beginning time and the ending
time in item (7).
(8) Washington, King, Seattle, My Residence or Business Name
(9) I-5, southbound, Milepost, near XYZ Exit.
(10) King County Flood Control District
(11) If you are represented by an attorney, select “Yes” and fill out the information requested. If you are not represented by an attorney, select “No” and proceed to question (12).
(12) List all witnesses who have knowledge of the incident in question, with their names, addresses, and telephone numbers. Also include a description of their knowledge. For example, if your sister was with you, when the alleged incident occurred, please include her name, address, telephone number, and indicate she witnessed the incident.
(13) Please describe the incident that resulted in injury or damage, specifically answering the questions who, what, where, when and why.
(14) If you reported this incident to law enforcement, safety, or security personnel, please provide a copy of the report or contact information to the person you spoke with.
(15) Please provide all of your medical providers with their names, address, telephone numbers, and the type of treatment. If you were treated for a personal injury, DO NOT attach medical records and bills; instead, mail copies or bring them in person to the address listed at the top of the form. You may also scan and email to kcc.flood@nullkingcounty.gov.
(16) Attach documents which support the claim’s allegations. DO NOT attach any documents that include personal protected information (e.g., Social Security numbers, medical information).
(17) Please provide the dollar amount for your damages, including your time loss, medical costs, property damage loss etc. This amount should represent your opinion of total compensation.
(18) If you were injured, please complete the Medicare Verification form and return it by email or in person to the address listed at the top of the form.

Mail, Email or Hand Deliver Related Information to:

For Mail / Hand Delivery: King County Flood Control District – Clerk of the Board
c/o King County Office of Risk Management Services
201 S. Jackson St., Suite 320
Seattle, WA 98104

Email: kcc.flood@nullkingcounty.gov

Claim Form

CLAIMANT INFORMATION

(1) Claimant's Name(Required)

First Middle Last

Date of Birth

(2) Current Residential Address

Street Address City State ZIP Code

(3) Mailing Address (if different)

Street Address City State ZIP Code

(4) Residential Address for Six Months Prior to the Date of the Incident (if different from current address)

Street Address City State ZIP Code

(5) CLAIMANT CONTACT INFORMATION

Home Phone Number

Cell Phone Number

Business Phone Number

Your Email Address(Required)

INCIDENT INFORMATION

(6) Date of Incident

Time

(7) If the incident occurred over a period of time, date of first and last occurrences:

From

Time

(8) Location of Incident

State and County

City (if applicable)

Place Where Occurred

(9) If the incident occurred on a street or highway:

Name of Street/Highway

Mile Post

At Intersection With or Nearest Intersecting Street

(10) District or Agency Alleged Responsible for Damage/Injury

(11) Are you represented by an attorney?

Yes

Attorney Name

Mailing Address

Street Address City State ZIP Code

Phone

(12) Name, addresses, and telephone numbers of all individuals involved in or witnesses to this incident, or knowledge of the claimant's resulting damage. Please include a brief description as to the nature and extent of each person’s knowledge.

(13) Describe the cause of the injury or damage. Explain the extent of property loss or medical, physical, or mental injuries.

(14) Has this incident been reported to law enforcement, safety or security personnel? If so, when and to whom?

(15) Names, addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings.

(16) Please attach documents which support the claim’s allegations.

Drop files here or

Accepted file types: jpg, png, pdf, xls, doc, docx, xlsx, Max. file size: 512 MB.

(17) I am claiming damages in the amount of ($):

(18) If you are injured, are you a Medicare beneficiary?

Yes

If Yes, please complete the Medicare Verification form and return it by mail or in person to the address at the top of the form. You can also scan and email it to kcc.flood@nullkingcounty.gov.

Please check the box below to indicate understanding that you must complete and return the Medicare Verification form, and that your claim will be held until all required information is received.

I understand

Is this an automobile-related claim?

Yes

License Plate #

Driver License #

Type of Auto (year, make, model)

Driver Address

Street Address City State ZIP Code

Driver Phone

Owner Address

Street Address City State ZIP Code

Owner Phone

Passenger #1 Name

First Last

Passenger #1 Address

Street Address City State ZIP Code

Passenger #2 Name

First Last

Passenger #2 Address

Street Address City State ZIP Code

The claimant must sign this claim form unless he or she is incapacitated, a minor, or a nonresident of the state, in which case it may be signed on behalf of the claimant by any relative, attorney, or agent representing the claimant.

I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

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.

Signature of Claimant(Required)