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					                                    Sound Transit Claim Form

 This form must be used to submit a claim for tort damages under RCW4.96. This form may also be used to submit a
 claim for insurance purposes by Sound Transit contractors.

 Failure to transmit this form in a timely fashion following any alleged damage may prohibit and/or delay any
 reimbursement, even if your claim is otherwise valid.

Instructions for Completing the Sound Transit Claim Form:
 Box       Name                             Description
 1         Who is Reporting The Alleged     Check the box to indicate who is submitting the Sound Transit Claim Form.
           Damage or Injury?                (Is the person completing this form Sound Transit personnel, Sound Transit
                                            Contractor personnel, or a member of the public?)

 2         Name                             Name of the person completing the Sound Transit Claim Form.

 3         Title                            Title of the person completing the Sound Transit Claim Form. (Leave blank
                                            if person is a member of the public).

 4         Work or Home Address at the      The Work or Home Address of the person completing the Sound Transit
           Time of the Alleged Damage or    Claim Form. Use the person’s Work or Home Address at the time the
           Injury                           alleged damage or injury occurred. (Members of the public MUST list their
                                            Home Address, while Sound Transit employees and Contractor personnel
                                            should list their Work location).

 5         City, State, Zip Code            The City, State, and Zip Code in which the person completing the Sound
                                            Transit Claim Form resides (Sound Transit employees and Contractor
                                            personnel should list their Work location).

 6         Telephone                        The Telephone number of the person completing the Sound Transit Claim
                                            Form (Members of the public should list the telephone number to reach
                                            them at home and indicate if their home phone is a cell phone. Sound
                                            Transit employees and Contractor personnel should list their Work
                                            Telephone number).

 7         Location                         The exact location at which the alleged damage or injury took place.
                                            Provide street address if possible.

 8         Type of Claim                    Check the boxes which most accurately describe the alleged damage or
                                            injury. (More than one box can be selected.)

 9         Date of Alleged Damage or        The Date that the alleged damage or injury occurred (month-day-year).
           Injury

 10        Time of Alleged Damage or        The time that the alleged damage occurred (please use 12 hour clock and
           Injury                           indicate am or pm).

 11        Has Damage Been Reported to      Check either Yes or No depending upon whether the alleged damage was
           Your Insurer                     reported to the claimant’s insurer.

 12        Amount of Damages Claimed        The total dollar amount of damages alleged.

 13        Description of Alleged Damage    A full and complete description of all alleged damages and/or injuries.
           or Injury                        Include the conduct and circumstances which brought about the injury or
                                            damage. Please be as detailed as possible. If the alleged damage or injury
                                            involved moving vehicles, provide directions of travel. Feel free to continue
                                            description on a second Claim Form if needed, and attach it to the original
                                            form. In addition, include pictures of the occurrence if any were taken.
14        If Involving Auto/Equipment:       If the events leading to the alleged damage or injury involved an automobile
                                             or heavy equipment of any kind, provide the Make, Model, Year, and
                                             License # of the vehicle. If multiple vehicles were involved, attach
                                             supplementary documents listing all additional vehicle descriptions.

15        Reported to Police?                Check either Yes or No depending upon whether the alleged damage was
                                             reported to the police.

16        If No, Why Not?                    If the alleged damage was not reported to the police, please explain why it
                                             was not reported.

17        Citation Issued?                   Check either Yes or No depending upon whether the police issued a citation
                                             to anyone in regards to the alleged damage.

18        Police Report #                    If the alleged damage was reported to the police, list the associated police
                                             report number. It is not necessary to wait for the issuance of a police report
                                             before transmitting the Sound Transit Claim Form.

19        Was an Incident Report Form        Is the person completing the form aware of whether a Sound Transit
          Previously Filed with Regard to    Incident Report Form was previously submitted to Sound Transit Risk
          the Alleged Damage?                Management with regard to the alleged damage or injury?(check the
                                             appropriate box). If yes, all previous Incident Report Forms previously filed
                                             MUST be attached.

20        Additional Home Addresses          Include addresses of all other residences at which the claimant resided
                                             during the six months immediately prior to the occurrence. Attach additional
                                             documents if necessary.

21        Home Phone                         The Home telephone number of the claimant .

22        Cell Phone                         The Cellular telephone number of the claimant.

23        Employer                           The Employer and the work address of the person completing the Sound
                                             Transit Claim Form.

24        Work Phone                         The Work telephone number of the person completing the Sound Transit
                                             Claim Form.

25        Witnesses or persons involved:     The full name, address and telephone number of any witnesses to the
                                             alleged damage or injury, and any persons otherwise involved in the
                                             incident which gave rise to the claim. If more than two witnesses were
                                             present, please attach additional information for each witness.

26        Signature of Claimant              The Signature of the person completing the Sound Transit Claim Form (“the
                                             Claimant”). This MUST be an original signature. This form may be
                                             completed electronically; however, a printed copy containing an original
                                             signature must be transmitted to Sound Transit.

27        Date                               The Date that the Sound Transit Claim Form was signed (month-day-year).

28        Printed Name and Title of          If the Claimant is incapacitated and unable to verify, present, or file the
          Person Verifying Claim (if         Claim Form, or if the Claimant is a minor or a nonresident of the state, this
          different from Claimant)           Claim Form may be verified, presented and filed by a relative, attorney or
                                             agent representing the Claimant.


After completing the following Sound Transit Claim Form, immediately transmit it and all substantiating documentation
via U.S. Mail to:
Attn: Board Administrator - Claim
Sound Transit
401 South Jackson Street
Seattle, WA 98104-2826
                                                      Sound Transit Claim Form
               Mail to: Attn: Board Administrator – Claim, Sound Transit, 401 S. Jackson St, Seattle, WA 98104-2826

A Claim for Damages must be submitted to the Sound Transit Board Administrator. RCW 4.96.                                             {For Sound Transit Use Only}
Under the Public Disclosure Act (RCW 42.56) this claim form and any documents submitted with                                                       Agency Operations
this claim form are considered public records and are subject to disclosure.                                                                       Railroad Operations
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN                                                              OCIP
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE
IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS. RCW 48.135.080                                                                              Partner Agency

1. Who is Reporting
the Alleged Damage        Sound Transit
or Injury:                Personnel                   2. Name:
                          Contractor
                          Personnel                   3. Title:
                          Member of the               4. Work or Home Address at
                          Public                      the Time of Alleged Damage:

                                                      5. City, State, Zip Code:
                                                      6. Telephone #:

7. Location:                                                                              8. Type of   Property             Bodily                    Damage
                                                                                          Damage       Damage               Injury                    to Project
                                                                                          or Injury:
                                                                                          (check all   Vehicle              Medical                   Injury to
                                                                                          that         Damage               Aid                       Another
                                                                                          apply)                            Necessary                 Person
9. Date of Alleged Damage:                                   11. Has Damage Been Reported to           Personal             Real                      12. Amount of
                                                             Your Insurer?                             Property             Property                  Damage Claimed:
10. Time of Alleged Damage:                                                                            Damage               Damage
                                                             Yes            No
13. Description of                                                                                                                    14. If Involving Auto/Equipment:
Alleged Damage
(include the                                                                                                                          Make
conduct and
circumstances                                                                                                                         Model
which brought                                                                                                                         Year
about the injury
or damage) :                                                                                                                          License #
Were pictures taken?       Yes (please include)       No

15. Reported to Police?                        Yes                 No                         17. Citation Issued?        Yes                 No
16. If Not Reported, Why Not?                                                                 18. Police Report #
19. Was an Incident Report Form Previously Filed in Regards to This Occurrence?                Yes            (If yes, please attach Incident Report)        No

20. Additional Home Address (list all addresses for 6 months                      23. Employer & Work
preceding occurrence. Attach additional list if necessary.):                      Address:


City:                      State:                        Zip:                     City:                                      State:            Zip:
21. Home Phone:                           22. Cell:                               24. Work Phone:
25 Witnesses:             (Name)                                                      (Address)                                                (Telephone #)




26. Signature of the Claimant:                                                                                       27. Date:
The Claimant verifies that all the information submitted in this Claim Form is true and correct.


28. Printed Name and Title of Person Verifying Claim (if different from Claimant):

				
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