HomeMy WebLinkAboutClaim for Damages FormINSTRUCTIONS FOR COMPLETING
The JEFFERSON COUNTY CLAIM FOR DAMAGE FORM
Before presenting a Jefferson County Claim for Damages Form please read these
instructions and the Claim for Damages Form in its entirety.
Type or print clearly in ink and sign the Claim for Damages Form. The Jefferson County
Claim for Damages Form must be signed by:
Claimant; or
Person holding a written power of attorney from the Claimant; or
Attorney in fact for the Claimant; or
Attorney admitted to practice in Washington State on the Claimant's behalf; or
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 understood.
The following are examples on how to complete the numbered items on the Claim for Damage form:
1) Smith, John Conner, 12101/1910
2) 222 One Way Street, Apt. Z, Port Townsend, WA 98368
3) Post Office Box 101, Quilcene, WA 98376
4) 360-123-4567 360-123-4567 360-123-4567
5) 222 One Way Street, Apt. Z, Port Townsend, WA 99201
6) claimantI@comcast.net
7) 01/01/2009, 8:00 a.m.
8) From: October 31, 2009 8:00 p.m. To: November 2, 20097:00 a.m.
9) Washington, Jefferson; Chimacum County maintained road.
10) Center Road northbound, milepost 4.0 Egg & I Road
11) Please describe the incident that resulted in the injury, or damages, specifically answering the
questions who, what, where, when and why.
12) Jefferson County Roads Department
Smith, Jenny, 222 One Way Street, Apt. Z, Port Townsend, WA 98368, (360)123-4567, riding
13) in the car at the time of the incident; Fitzgerald, Who sits, 3287 Wonderful Lane, Brinnon, WA
98331, (360)111-1111; witnessed the incident.
14) List address and telephone numbers of all County Departments and employees having
knowledge about this incident.
List all other witnesses having knowledge of the incident in question, with their names,
addresses, and telephone numbers that are not listed within items (12) and (13). Also include
15) a description of their knowledge. For example, if your sister was with you, when the alleged
incident occurred, please include her name, address, and telephone number, and indicate
she witnessed the incident.
Instructions for Completing Jefferson County Claim for Damages Form
16) Describe how the damages or injury was caused.
If you reported this incident to law enforcement, safety or security personnel, please provide
17) the name of the person you spoke with, and the date and time you spoke to them and include
a copy of the report or contact information for the person with whom you spoke.
Please provide a list of all your medical providers, including their names, address, telephone
18) numbers, and the type of treatment. Please attach copies of all medical records and billings if
you were treated for a personal injury under this claim.
19) Attach documents which support the claim's allegations.
20) 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 damages.
21) If you were injured, please indicate if you are Medicare eligible and provide your Medicare
number. If you are presenting a personal injury claim, submit the Medical Release form.
22) Please provide the name of the company that provides you insurance for this type of claim.
23) If your claim involves vehicle accident, submit the Vehicle Collision Form
Page 2 of 2 - Claim Form Instructions
Claim #:
JEFFERSON COUNTY
Claim for Damages
This Claim Form is provided solely as an accommodation to claimants, and the County makes no representations as to
its legal sufficiency. Responsibility for complying with all requirements of State law regarding claims rests with the
claimant. No County Employee is authorized to advise a claimant in completing this form or reviewing its sufficiency.
The County expressly disclaims responsibility for any such advice or review. Information requested on this form may be
subject to public disclosure. This claims form must be presented with an original signature and cannot be submitted
electronically (by e-mail or fax.)
PLEASE TYPE OR PRINT IN INK
RISK MANAGER
Mail or Deliver JEFFERSON COUNTY COURTHOUSE
original Claim t0: 1820 JEFFERSON STREET
9 PO BOX 1220
PORT TOWNSEND, WA 98368
CLAIMANT INFORMATION
Business Hours:
Mon. - Fri. 8:30 a.m. to 4:30 p.m.
Closed on weekends and officials
State and Federal Holidays
I, AS THE CLAIMANT, HEREIN BELIEVE THE CONTENTS OF THIS CLAIM TO BE
TRUE. I HEREBY PRESENT A CLAIM FOR DAMAGES AGAINST JEFFERSON
COUNTY, WASHINGTON, BASED UPON THE FOLLOWING INFORMATION AS
REQUIRED BY RCW 4.96.020 AND 36.45.010:
If more space is needed to answer any items, attach additional sheet and specify the item number.
My name, address and phone number at the time of presenting and filing this claim is:
1) Name Date of
2) Physical Residence Address:
3) Mailing Address (if different than residence):
4) Daytime Phone Numbers:
(Home)
(mMddlyy)
5) Physical Residential address for six (6) months immediately prior to the date of the incident (if different from current
address):
6) Your e-mail address:
INCIDENT INFORMATION
7) Date Incident Occurred: Time:
(mmiddryyyy
8) If the incident occurred over a period of time, date of first and last occurrences:
FROM: Time: TO: Time:
AM. w P.M.
9) Location of
& cowm
n
AM. w P.M.
(Place wry ocmned)
10) If the incident occurred on a street or highway:
(Name of sheelRo vay) (Milepost)
(al intersection wAh a neared nWsedig sbceq
11) The nature of the damages or injury I sustained are:
12) Jefferson County Department(s) or employee(s) allegedly responsible for damage/injury:
13) Name(s) address, and telephone number(s) of all persons involved in, or witness to, this incident:
14) Name(s), address, and telephone number(s) of all Jefferson County department(s) or employee(s) having
knowledge of this incident:
15) Name(s), address, and telephone number(s) of all individuals not already identified in (12) and (13) above that have
knowledge regarding the liability issues involved in this incident, or knowledge of the claimant's resulting damages.
Please include a brief description as to the nature and extent of each person's knowledge.
16) Describe the cause of the damages or injury. Explain the extent of property loss or medical expenses.
17) Has the incident been reported to law enforcement, safety or security personnel? If so, when was it reported and to
whom?:
18) Provide name(s) addresses, and telephone number(s) of treating medical providers. Attach copies of all medical
reports and billings:
19) Please attach all documents which support your claim:
20) 1 claim damages from Jeffrson County in the sum of $
The amount of damages sustained must be itemized
21) If you are injured, are you a Medicare beneficiary?
Yes No
If Yes, please provide your Medicare #
22) The name of my insurance agency is:
23) If your claim involves a motor vehicle accident, complete, sign and include the attached vehicle collision form. Two
(2) estimates of the cost of repairs must be attached to this claim with the amount of damages sustained itemized.
24) If you are presenting a personal injury claim, complete, sign and include the attached Medical Release form
This claim form must be signed by the Claimant, a person holding a written power of attorney from the Claimant to serve
as the attorney in fad for the Claimant, by an attorney admitted to practice in Washington State on the Claimant's
behalf, or by a court -approved guardian or Guardian Ad [item on behalf of the Claimant.
I declare, under penalty of perjury under the laws of the State of Washington, that the foregoing is true and
correct.
a Clamant
Place (Gy & C.m4)
T.tle (V Gam is a Ca Wy)
Page 1 of 2
The Centers for Medicare & Medicaid Services (CMS) is the federal agency that oversees the Medicare
program. Many Medicare beneficiaries have other insurance in addition to their Medicare benefits. Sometimes,
Medicare is supposed to pay after the other insurance. However, if certain other insurance delays payment,
Medicare may make a "conditional payment' so as not to inconvenience the beneficiary, and recover after the
other insurance pays.
Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA), a new federal law
that became effective January 1, 2009, requires that liability insurers (including self -insurers), no-fault insurers,
and workers' compensation plans report specific information about Medicare beneficiaries who have other
insurance coverage. This reporting is to assist CMS and other insurance plans to properly coordinate payment
of benefits among plans so that your claims are paid promptly and correctly.
We are asking you to the answer the questions below so that we may comply with this law.
Please review this picture of the
Medicare card to determine if you
have, or have ever had, a similar
Medicare card.
Section I
1-DOOJdE�ICRkE iL800.609i221
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i1EJICIINE 3FMEfliS TO MS 11 iWFFS'
Are you presently, or have you ever been, enrolled in Medicare Part A or Part B? ❑Yes ❑No
!f' es, Lease eTe ow .-, tf na; " r€ttaed taSectioiidd.
Full Name. Fffease nt'the nam"e
&Xactt as if
a' ars'iab
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availdble.
I
Medicare Claim Number: 3
Date of Birth
Mo1Da !Year
Social Security Number:
If Medicare Claim Number is Unavailable
Sex
❑Female
❑Male
Section II
I understand that the information requested is to assist the requesting insurance arrangement to accurately
coordinate benefits with Medicare and to meet its mandatory reporting obligations under Medicare law.
Claimant Name (Please Print)
Claim Number
Name of Person Completing This Form If Claimant is Unable (Please Print)
Signature of Person Completing This Form Date
If you have completed Sections I and 11 above, stop here. If you are refusing to provide the information
requested in Sections I and It, proceed to Section lll.
Page 2 of 2
Section III
Claimant Name (Please Print) Claim Number
For the reason(s) listed below, I have not provided the information requested. I understand that if I am a
Medicare beneficiary and I do not provide the requested information. I may be violating obligations as a
beneficiary to assist Medicare in coordinating benefits to pay my claims correctly and promptly.
Reason(s)for Refusal to Provide Requested Information:
Signature of Person Completing This Form Date
CONSENT TO RELEASE
The language below should be used when you, a Medicare beneficiary, want to authorize someone other than
your attorney or other representative to receive information, including identifiable health information, from the
Centers for Medicare & Medicaid Services (CMS) related to your liability insurance (including self-insurance),
no-fault insurance or workers' compensation claim.
your name exactly as shown on your Medicare card) hereby
authorize the CMS, its agents and/or contractors to release, upon request, information related to my
injury/illness and/or settlement for the specified date of injury/illness to the individual and/or entity listed
below:
CHECK ONLY ONE OF THE FOLLOWING TO INDICATE WHO MAY RECEIVE INFORMATION
AND THEN PRINT THE REQUESTED INFORMATION:
(If you intend to have your information released to more than one individual or entity, you must complete a
separate release for each one.)
( X) Insurance Company
Name of entity:
Contact for above entity:
Address:
Telephone:
( ) Workers' Compensation Carrier ( ) Other
Washington Counties Risk Pool
Tammy Cahill
2558 R.W. Johnson Road SW #106
Tumwater, WA 98512
360-292-4484
(Explain)
CHECK ONE OF THE FOLLOWING TO INDICATE HOW LONG CMS MAY RELEASE YOUR
INFORMATION (The period you check will run from when you sign and date below.):
( ) One Year ( ) Two Years ( ) Other
(Provide a specific period of time)
I understand that I may revoke this "consent to release information" at any time, in writing.
MEDICARE BENEFICIARY INFORMATION AND SIGNATURE:
Beneficiary Signature:
Date signed:
Note: if the beneficiary is incapacitated, the submitter of this document will need to include documentation establishing the authority
of the individual signing on the beneficiary's behalf. Please visit www.msnrc.info for further instructions.
Medicare Health Insurance claim Number (The number on your Medicare card.):
Date of Injury/Illness: