IMPORTANT: Must be completed
IMPORTANT: Must be completed
Risk Management | EGS
E-mail:
risk.management@oregon.gov
in Acrobat Reader.
PO Box 12009
in Acrobat Reader.
Website:
State of Oregon: Risk Management
Salem, OR 97309-0009
Download Reader here
Find this form on the Web at:
503-373-7475
https://www.oregon.gov/das/Risk/Documents/Form_AllClaimsNonAuto.pdf
503-373-7337 fax
         
OREGON STAND
ARD TORT CLAIM FORM
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)
Report Number:
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. DAS-RM Standard form
IMPORTANT: Must be completed
IMPORTANT: Must be completed
Risk Management | EGS
E-mail:
risk.management@oregon.gov
in Acrobat Reader.
PO Box 12009
in Acrobat Reader.
Website:
State of Oregon: Risk Management
Salem, OR 97309-0009
Download Reader here
Find this form on the Web at:
503-373-7475
https://www.oregon.gov/das/Risk/Documents/Form_AllClaimsNonAuto.pdf
503-373-7337 fax
         
OREGON STAND
ARD TORT CLAIM FORM
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)
Report Number:
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. DAS-RM Standard form
Risk Management | EGS
E-mail:
risk.management@oregon.gov
PO Box 12009
Website:
State of Oregon: Risk Management
Salem, OR 97309-0009
Find this form on the Web at:
503-373-7475
https://www.oregon.gov/das/Risk/Documents/Form_AllClaimsNonAuto.pdf
503-373-7337 fax
         
OREGON STAND
ARD 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
Centers for Medicare and Medicaid Services - Home
Website.
information at
  
15. Last Name
First name
Middle initial
16. Date of Birth (mm/dd/yyyy)
17. Gender
M
F
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
  
21. Did the airbag deploy?
Yes
No
22. Describe your injury:
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?
28. If yes, explain:
Yes
No
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. DAS-RM Standard form
Risk Management | EGS
E-mail:
risk.management@oregon.gov
PO Box 12009
Website:
State of Oregon: Risk Management
Salem, OR 97309-0009
Find this form on the Web at:
503-373-7475
https://www.oregon.gov/das/Risk/Documents/Form_AllClaimsNonAuto.pdf
503-373-7337 fax
         
OREGON STAND
ARD 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
Date
PRINT
SUBMIT
PRINT  
EMAIL  
Page 3 of 3
Revised 06/26/2018
Form No. DAS-RM Standard form
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