Free Oregon Tort Claim Form
Content Overview
The Oregon Tort Claim form serves as a crucial document for individuals seeking compensation for damages or injuries caused by state agencies. This form requires claimants to provide essential information, including their personal details, the specifics of the incident, and the nature of the damages incurred. Claimants must specify the date and location of the incident, as well as describe what happened. If applicable, they should include details about any police reports filed, along with the relevant agency's name. Furthermore, the form prompts individuals to identify the state agency they believe is responsible and to provide witness information if available. For those who have suffered bodily injuries or property damage, additional questionnaires are included to gather pertinent medical and damage-related information. It is important to note that claims must be submitted within 180 days of the incident, as stipulated by Oregon law. The completed form can be sent to the Risk Management office via email or postal mail, ensuring that all required sections are filled out accurately to avoid delays in processing. This structured approach not only aids in the efficient handling of claims but also ensures that claimants have a clear understanding of the information needed to support their cases.
Similar forms
- Personal Injury Claim Form: Similar to the Oregon Tort Claim form, this document is used to report injuries sustained due to someone else's negligence. Both forms require detailed information about the claimant, the incident, and any injuries incurred.
- Property Damage Claim Form: This form is focused on damages to personal property. Like the Tort Claim form, it asks for specifics about the incident, including descriptions and estimates of damages.
- Workers' Compensation Claim Form: This document is used by employees to claim benefits for work-related injuries. Both forms require information about the incident and the injuries, although the Workers' Compensation form is specific to employment-related incidents.
- Auto Accident Claim Form: This form is used to report claims related to vehicle accidents. Similar to the Oregon Tort Claim form, it gathers details about the incident, damages, and any injuries, but it is specifically tailored for auto-related incidents.
- Motorcycle Bill of Sale Form: Essential for motorcycle transactions, this legal document records the sale and transfer of ownership, ensuring all relevant details are documented. For more information, visit Forms Georgia.
- Medical Malpractice Claim Form: This document is used to report claims against healthcare providers for negligence. Both forms require detailed accounts of the incident and the resulting damages or injuries, emphasizing the need for thorough documentation.
- General Liability Claim Form: This form is used by businesses to report claims for injuries or damages that occur on their property. Like the Oregon Tort Claim form, it requires information about the incident and the claimant, focusing on liability and damages.
Preview - Oregon Tort Claim Form
Risk Management | EGS
PO Box 12009
Salem, OR
IMPORTANT: Must be completed |
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in Acrobat Reader. |
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Website: State of Oregon: Risk Management |
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Find this form on the Web at: https://www.oregon.gov/das/Risk/Documents/Form_AllClaimsNonAuto.pdf
OREGON STANDARD TORT CLAIM FORM
Claimant Information
Incident Information
State Agency
Damages
Witnesses
1.Claimant name:
Last Name |
First |
Middle |
Date of Birth (mm/dd/yyyy) |
2.Current residential address: __________________________________________________________________________________
3.Mailing address (if different): _________________________________________________________________________________
4.Claimant’s telephone number: Home _____________________________________________ Alternate ______________________
5.Claimant’s email address:
6.Date of Incident: ____________________________Time: _________________________ a.m. p.m.
7.Location of incident: ________________________________________________________________________________________
8.Description of incident:
9. Police report? yes no |
If yes, please provide the report number and the police agency name (City, County or State) |
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Report Number: |
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Police Agency Name: |
10. Name of State agency involved and why you believe they are responsible for your damage/injury.
11.Name of employee (if applicable):
12.If injuries occurred, please complete the bodily injury questionnaire.
13.If property damage occurred, describe it below and list and provide photographs and 2 estimates.
14. Witness name, address, phone number and relationship:
Page 1 of 3
Revised 06/26/2018
Form No.
Risk Management | EGS |
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PO Box 12009 |
Website: State of Oregon: Risk Management |
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Salem, OR |
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Find this form on the Web at: |
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https://www.oregon.gov/das/Risk/Documents/Form_AllClaimsNonAuto.pdf |
OREGON STANDARD TORT CLAIM FORM
Bodily Injury Questionnaire: IMPORTANT: We are required by federal law to obtain the information in questions
15 through 17. Failure to provide this information will result in delays in resolving your claim. You can find further information at Centers for Medicare and Medicaid Services - Home Website.
Bodily Injury Questionnaire
15. |
Last Name |
First name |
Middle initial |
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16. |
Date of Birth (mm/dd/yyyy) |
17. Gender |
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M F |
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18. Is this related to an auto accident? (If no, skip to question 22)
19. If yes, where were you seated in vehicle?
Driver Front right passenger Rear right passenger Rear left passenger Other
20. Seatbelt used? Yes |
No |
What kind? Lap Shoulder None |
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21. Did the airbag deploy? |
Yes |
No |
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22. Describe your injury: |
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23. When did you first notice you were injured?
24. Have you sought medical treatment? Yes No |
25. If yes, list the medical providers you have seen: |
26. Approximate amount of medical costs incurred to date:
27. Is future treatment expected? Yes No |
28. If yes, explain: |
29. Do you have any prior injuries to the injured body part(s)? Yes
No |
30. If yes, explain: |
31. Any other information you would like to provide us:
Page 2 of 3
Revised 06/26/2018
Form No.
Risk Management | EGS
PO Box 12009
Salem, OR
Website: State of Oregon: Risk Management
Find this form on the Web at: https://www.oregon.gov/das/Risk/Documents/Form_AllClaimsNonAuto.pdf
OREGON STANDARD TORT CLAIM FORM
ADDITIONAL INFORMATION:
Per ORS 30.275, Risk Management must receive your claim within 180 days from the date of loss.
I declare the foregoing is true and correct to the best of my knowledge.
Signature of claimant |
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Date |
Page 3 of 3
Revised 06/26/2018 Form No.
Key takeaways
When filling out the Oregon Tort Claim form, it is essential to keep several key points in mind to ensure your claim is processed smoothly. Here are some important takeaways:
- Use Acrobat Reader: The form must be completed using Acrobat Reader. This ensures compatibility and prevents formatting issues.
- Timely Submission: According to ORS 30.275, your claim must be submitted within 180 days from the date of the incident. Be mindful of this deadline to avoid complications.
- Provide Accurate Information: Fill in all required fields accurately, including your name, contact details, and specifics about the incident. Incomplete forms can lead to delays.
- Include Supporting Documentation: If applicable, attach any police reports, photographs, and estimates for property damage. This evidence strengthens your claim.
- Detail Your Injuries: If you sustained injuries, complete the bodily injury questionnaire thoroughly. Include information about medical treatment and costs incurred.
- Contact Information: Ensure that your contact information is current. This allows the Risk Management team to reach you easily for any follow-up questions or clarifications.
By following these guidelines, you can help facilitate a smoother claims process and ensure that your concerns are addressed promptly.
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File Details
| Fact Name | Details |
|---|---|
| Governing Law | The Oregon Tort Claim form is governed by Oregon Revised Statutes (ORS) 30.275. |
| Submission Deadline | Claims must be submitted within 180 days from the date of the incident. |
| Required Format | The form must be completed using Acrobat Reader to ensure proper submission. |
| Contact Information | The form can be submitted to Risk Management via email at risk.management@oregon.gov or by mail to PO Box 12009, Salem, OR 97309-0009. |
| Form Location | The Oregon Tort Claim form is available online at this link. |
| Claimant Information | Claimants must provide personal details, including name, address, and contact information. |
| Incident Details | Information about the incident, such as date, time, location, and description, is required. |
| Witness Information | Claimants should include details of any witnesses, including names and contact information. |
| Bodily Injury Questionnaire | If applicable, claimants must complete a bodily injury questionnaire to provide necessary medical information. |
Documents used along the form
The Oregon Tort Claim form is an essential document for individuals seeking compensation for damages or injuries caused by state agencies. Along with this form, there are several other documents and forms that may be necessary to support a claim. Each of these documents serves a specific purpose in the claims process, helping to provide a clearer picture of the incident and the resulting damages.
- Bodily Injury Questionnaire: This document gathers detailed information about any injuries sustained during the incident. It includes questions about the nature of the injury, medical treatment received, and related costs. Completing this questionnaire is crucial for establishing the extent of injuries and potential compensation.
- Police Report: If law enforcement was involved, a police report can provide an official account of the incident. This report often includes witness statements, evidence, and the police agency's assessment of the situation, which can be vital in substantiating a claim.
- Medical Records: These records document the treatment received for injuries related to the incident. They can include hospital records, physician notes, and bills, all of which help to establish the medical costs incurred and the severity of the injuries.
- Estimates for Property Damage: If property was damaged in the incident, providing two estimates for repair costs can help support a claim. These estimates should be from reputable sources and clearly outline the necessary repairs.
- Vehicle Purchase Agreement: It's important to have a documentation that governs the vehicle transaction process. For those looking to buy or sell a vehicle in California, you can follow this https://legalpdf.org/ to ensure an accurate completion of your agreement.
- Witness Statements: Statements from individuals who witnessed the incident can provide additional context and support for the claim. These statements should detail what the witness observed and their relationship to the claimant.
- Claimant's Affidavit: This is a sworn statement by the claimant affirming the truthfulness of the information provided in the claim. It serves to reinforce the credibility of the claim and can be an important component in the review process.
Gathering and submitting these documents along with the Oregon Tort Claim form can significantly enhance the chances of a successful claim. Each document plays a role in painting a comprehensive picture of the incident and the damages incurred, ultimately aiding in the resolution of the claim.