The Oregon Tort Claim form is a legal document used to file claims against the state for damages or injuries caused by the state's actions or negligence. Completing this form is essential for anyone seeking compensation, as it outlines the necessary information about the claimant, the incident, and the damages incurred. Understanding how to properly fill out this form can significantly impact the outcome of your claim.
The Oregon Tort Claim form is a crucial document for individuals seeking compensation for damages or injuries caused by the actions of a state agency or its employees. This form is designed to gather essential information from the claimant, including personal details such as name, address, and contact information, as well as specifics about the incident in question. Claimants must provide a detailed description of the event, the date and location, and any relevant police report information, if applicable. Additionally, the form requires the identification of the state agency involved and the basis for their liability. For those who have sustained bodily injuries, a questionnaire is included to collect vital medical information, such as treatment received and ongoing medical needs. The form also emphasizes the importance of submitting claims within 180 days of the incident, in accordance with Oregon law. By completing the Oregon Tort Claim form accurately and thoroughly, claimants can ensure that their claims are processed efficiently, paving the way for potential resolution and compensation.
Risk Management | EGS
PO Box 12009
Salem, OR 97309-0009 503-373-7475
503-373-7337 fax
IMPORTANT: Must be completed
E-mail: risk.management@oregon.gov
in Acrobat Reader.
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
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)
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:
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Revised 06/26/2018
Form No. DAS-RM Standard form
Salem, OR 97309-0009
503-373-7475
Find this form on the Web at:
https://www.oregon.gov/das/Risk/Documents/Form_AllClaimsNonAuto.pdf
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.
First name
Middle initial
16.
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
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? Yes No
28. If yes, explain:
29. Do you have any prior injuries to the injured body part(s)? Yes
30. If yes, explain:
31. Any other information you would like to provide us:
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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
EMAIL
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Revised 06/26/2018 Form No. DAS-RM Standard form
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