Claim for Damages – Automobile OnLine

Tuesday March 16th

cityrecorder

Claim for Damages – Automobile Administrative Policy 2-9

Please read the entire Damage Incident Report before completing. This form should be filed with the City Recorder at the City of Oregon City as soon as possible after the date of the occurrence, giving rise to the claim for damages or relief. Cooperation in completing this form will expedite claim processing.

Download the Claim for damages - Auto form to complete offline.
Download an incident diagram to mark up and submit using this form (below).

If you have any questions, please contact the City Recorder at 503-496-1505 or nide@orcity.org.

PLEASE ATTACH ESTIMATES, PHOTOS, AND ANY OTHER DOCUMENTATION WITH THIS CLAIM FORM.

Instructions for completing attached diagram of the incident:

For all accident claims, place on attached diagram the names of streets, indicating North, East, South, and West.
Indicate place of accident by “X” and by showing house numbers or distance to street corners.
If City vehicle was involved, designate by letter “A” location of City vehicle when you first saw it, and by “B” location of yourself or your vehicle when you first saw City vehicle.
Location of City vehicle at the time of the accident by “A1” and location of yourself or your vehicle at the time of the accident by “B1” and the point of impact by “X.”

NOTE: If diagram does not fit this situation, attach a proper diagram signed by claimant.

Contact Information

Name of Claimant: *

Home Address:

Work Address:

Home Phone: *

Work Phone:

email address: *

Damage or Injury Information

When Damage or Injury Occurred :

When did damage or injury occur? Give full details, date, time of day.

Where Damage or Injury Occurred:

Where did damage or injury occur? Describe fully and locate on diagram on attached sheet.

Physical Conditions Surrounding Occurrence:

Indicate the physical conditions surrounding the occurrence (i.e., weather condition, lightness or darkness, condition of the road, traffic, power lines, etc.), when applicable.

How Damage or Injury Occurred:

How did damage or injury occur?

Name(s) of City Employee(s):

Names of any City employees alleged to have caused the injury, damage, or loss, if known.

Act or Omission by City:

What particular Act or Omission on the part of the City or its employees do you claim caused the injury or damage?

Damage or Injuries Claimed:

What damage or injuries do you claim resulted? Give full extent of injuries or damage claimed. List the sum you claim and an account of each item of injury or damage.

Witness, Doctors, and Hospitals:

Names and addresses of witness, doctors, and hospitals.

Other Details:

Attach Diagram of Incident:

Download and save a blank diagram (opens in a new tab)

Attach Photo of Incident:

Attach a photo of incident

Police Information

Was the Accident Investigated by Any Police Department?:

Yes

Name or Badge Number:

If yes, please furnish name or badge number of officer.

Insurance Information:

Insurance payments, if any, received by you on account of this damage or injury and the name of the insurance company.

Expenditures