Claims for Damages - Vashon Fire

Agent for Claims

Pursuant to the provisions of RCW 4.96.020, the Board of Commissioners of Vashon Island Fire & Rescue has appointed the below-listed agent to receive any claims for damages made under RCW Chapter 4.96:

Agent Appointed: Fire Chief

Office Address: 10020 SW Bank Rd. / PO Box 1150, Vashon, WA 98070

Business Hours: Monday – Friday, 8:00am – 5:00pm

Resolution No. 17-362

Appointment of Agent to Receive Claims for Damages

Standard tort claim form

Pursuant to Chapter 4.96 RCW, this form is for filing a tort claim against King County Fire Protection District No. 13, d.b.a. Vashon Island Fire and Rescue. Some of the information requested on this form is required by RCW 4.96.020 and may be subject to public disclosure.

CLAIMANT INFORMATION

1. Claimant's name(Required)

First Middle Last

1. Date of birth(Required)

2. Current residential address(Required)

Street Address Address Line 2 City State ZIP Code

Mailing address

Is mailing address different than current residential address?

3. Mailing address(Required)

Street Address Address Line 2 City State ZIP Code

Residential address at time of incident

Is residential address at time of incident different from current address?

4. Residential address at time of incident

Street Address Address Line 2 City State ZIP Code

5. Claimant's daytime home phone

Claimant's daytime business phone

6. Claimant's email address(Required)

INCIDENT INFORMATION

7. Date of the incident(Required)

Time(Required)

From (start date)

Start time

To (end date)

End time

Where did incident take place?(Required)

On a street or highway

Somewhere other than a street or highway

9. Location of incident(Required)

Include State & County, City (if applicable), and Place where incident occurred

10. Incident occurred on a street or highway(Required)

Include name of street or highway, milepost number, Intersection of nearest intersecting street

11. Agency or department alleged responsible for damage/injury(Required)

12. Names, addresses and telephone numbers of all persons involved in or witness to this incident:(Required)

13. Names, addresses and telephone numbers of all District employees having knowledge about this incident(Required)

14. Names, addresses and telephone numbers 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.

15. Describe the cause of the injury or damages. Explain the extent of property loss or medical, physical or mental injuries.

16. Has this incident been reported to law enforcement, safety or security personnel? If so, when and to whom?

17. Names, addresses and telephone numbers of treating medical providers.

Attach copies of all medical reports and billings.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 256 MB.

18. Please attach documents which support the claim’s allegations.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 256 MB.

19. I claim damages from Vashon Island Fire and Rescue in the sum of

This Claim form must be signed by the Claimant, a person holding a written power of attorney from the Claimant, by the attorney in fact 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 litem 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.

Enter your full name as your signature(Required)