Homepage Blank Oregon Tort Claim PDF Template
Navigation

When individuals in Oregon find themselves needing to file a claim for damages or injuries against a state agency, the Oregon Standard Tort Claim Form serves as a vital first step in this legal process. This comprehensive document, overseen by the State of Oregon's Risk Management division, requires claimants to provide detailed information about themselves, the incident in question, involved state agencies, and any witnesses. It includes sections for the claimant's personal details, a thorough description of the incident, whether a police report was filed, details of any injuries sustained with a bodily injury questionnaire, and descriptions of property damage including the necessity to attach photographs and cost estimates. Crucially, the form also adheres to federal requirements for specific information, highlighting its importance in ensuring claims are processed efficiently. The submission of this form, available through the Oregon government’s website, must occur within a strict 180-day period following the incident, emphasizing the importance of timely action. Furthermore, the claimant's declaration of truth and acknowledgment of the form's accuracy at the time of completion underpin the seriousness with which these claims are handled. This form not only facilitates a structured means for individuals to report their grievances but also underscores the state’s procedural approach to addressing and potentially resolving such claims.

Preview - Oregon Tort Claim Form

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:

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

 

503-373-7475

Find this form on the Web at:

503-373-7337 fax

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

 

 

 

 

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? 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. DAS-RM Standard form

Risk Management | EGS

PO Box 12009

Salem, OR 97309-0009 503-373-7475

503-373-7337 fax

E-mail: risk.management@oregon.gov

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

 

Date

PRINT

EMAIL

Page 3 of 3

Revised 06/26/2018 Form No. DAS-RM Standard form

Form Data

Fact Name Description
Form Purpose The Oregon Standard Tort Claim Form is used to report damage or injury claims against the state.
Contact Information Risk Management's contact is PO Box 12009 Salem, OR 97309-0009, phone 503-373-7475, and fax 503-373-7337.
Email and Website Email address is risk.management@oregon.gov. The form can be found at the State of Oregon: Risk Management website.
Completion Requirement The form must be completed in Acrobat Reader according to the instructions provided.
Claim Information Needed Claimant information, incident information, state agency and employee involved, damages, and witnesses are required.
Bodily Injury Questionnaire Included in the form, with federal law requiring certain information to be provided to avoid delays.
Time Limit for Filing Per ORS 30.275, claims must be received by Risk Management within 180 days from the date of loss.
Submission Declaration The claimant must declare the information provided is true and correct and provide their signature and date of submission.

Instructions on Utilizing Oregon Tort Claim

Filling out the Oregon Standard Tort Claim Form is a crucial step towards submitting your claim. This detailed procedure ensures that all the necessary information is provided, allowing the State of Oregon: Risk Management to process your claim efficiently. For a smooth experience, gather all relevant documents, including any police reports, medical records, and evidence of damages, before you start. Now, let’s go through the steps to fill out the form accurately.

  1. Download the latest version of Acrobat Reader to ensure compatibility with the form.
  2. Go to the provided web address to download the Oregon Standard Tort Claim Form: https://www.oregon.gov/das/Risk/Documents/Form_AllClaimsNonAuto.pdf
  3. Start with the Claimant Information section:
    • Enter your full name (Last, First, Middle) and Date of Birth in the respective fields.
    • Provide your current residential address. If your mailing address is different, include that as well.
    • Fill in your telephone number(s) and email address for contact purposes.
  4. Move to the Incident Information section:
    • Specify the date and time of the incident, including AM or PM.
    • Describe the location and a detailed account of the incident.
    • If a police report was filed, indicate "yes," and provide the report number and police agency name.
    • Identify the State agency involved and explain why they are believed to be responsible for the incident.
    • Include the name of the employee involved, if applicable.
  5. For the Damages section, if injuries were sustained, complete the bodily injury questionnaire. If property damage occurred, describe the damage, and include photographs and two estimates of repair costs.
  6. In the Witnesses section, list the name, address, telephone number, and relationship of any witnesses to the incident.
  7. Complete the Bodily Injury Questionnaire:
    • Fill out your name, date of birth, and gender.
    • Answer whether the injury is related to an auto accident and provide further details as required.
    • Describe the injury, when you first noticed it, and if medical treatment was sought.
    • List medical providers seen, approximate medical costs incurred, and whether future treatment is expected.
    • If there are prior injuries to the same body part(s), explain.
    • Include any additional information that might assist in understanding the severity and scope of your injuries or damages.
  8. In the Additional Information section, note the importance of submitting your claim within 180 days from the date of the loss, as per ORS 30.275.
  9. Finally, review all the information provided for accuracy. Sign and date the form in the designated area.
  10. Send the completed form to the address provided on the top of the form or as directed by State of Oregon: Risk Management.

After submitting the form, the State of Oregon: Risk Management will process your claim. They may contact you if additional information is needed. Ensure you keep copies of all documents submitted for your records. This meticulous approach helps in safeguarding your rights and facilitates a thorough review of your claim.

Obtain Answers on Oregon Tort Claim

Frequently Asked Questions about the Oregon Tort Claim Form

  1. What is the purpose of the Oregon Standard Tort Claim Form?

    This form is designed for individuals who intend to file a claim against an Oregon state agency or its employees due to damage or injury believed to be caused by the agency or its employee's negligence or wrongful actions. It collects all necessary information to process the claim.

  2. How do I submit the Oregon Standard Tort Claim Form?

    The form should be filled out using Acrobat Reader and then mailed or faxed to Risk Management at the provided addresses. Ensure that the form is complete to avoid delays.

  3. Can I email the completed form to Risk Management?

    Yes, the email address to send the completed form is risk.management@oregon.gov. Ensure that your form is signed and all necessary documentation is attached before emailing.

  4. What should I do if I don’t have a police report?

    It's not mandatory to have a police report to submit a tort claim, but if the incident was reported to the police and you have the report, include the report number and the name of the agency. If you don't have a report, simply mark 'no' for the police report question.

  5. What information is required for a property damage claim?

    For property damage, you need to describe the damage in detail, attach photographs of the damage, and provide at least two estimates for the repair costs.

  6. What if I need to specify injuries in the Bodily Injury Questionnaire?

    The Bodily Injury Questionnaire section must be completed, detailing the nature of your injuries, when and where you first noticed them, any medical treatment received, and an estimation of medical costs. If an auto accident was involved, additional details are required.

  7. Is there a deadline for submitting the claim form?

    Yes, according to ORS 30.275, your claim must be received by Risk Management no later than 180 days from the date of the loss. Late submissions may not be considered, emphasizing the importance of timely filing.

  8. Who should I contact if I have questions about filling out the form?

    If you have any questions or need assistance with the form, you can contact Risk Management at 503-373-7475 or via email at risk.management@oregon.gov. They can provide guidance and ensure your claim is properly submitted.

Common mistakes

  1. Filling out the form manually instead of using Acrobat Reader, as expressly required, can lead to processing delays or even the rejection of the claim. The form specifies that it must be completed in Acrobat Reader, underscoring the importance of digital accuracy and readability.

  2. Overlooking the importance of providing a detailed incident description, including specific times and locations, can weaken the claim. Precise details paint a clearer picture of the incident, aiding in the claim’s evaluation.

  3. Not including a police report number and agency name when applicable. A police report can substantially support a claimant's case, providing third-party documentation of the incident.

  4. Omitting witness information, such as names, addresses, and phone numbers, denies the Risk Management team access to crucial corroborating testimony, which can bolster the claim.

  5. Failure to answer questions 15 through 17 related to the Bodily Injury Questionnaire can result in delays, as these are required under federal law. This information is vital for compliance and accelerating the claim’s resolution.

  6. Not providing photographs and two estimates for property damage overlooks the opportunity to visualize and quantify the extent of damage, which is essential for validating and assessing the claim.

  7. Missing the 180-day submission deadline per ORS 30.275 can lead to an outright denial of the claim. Adhering to this timeframe is critical for the claim's eligibility.

Being thorough and timely, providing complete and accurate information, and adhering to specified submission processes are essential steps in successfully navigating the Oregon Standard Tort Claim process. These actions ensure that claims are processed efficiently and that claimants have the best chance of a favorable resolution.

Documents used along the form

When preparing to file an Oregon Standard Tort Claim Form, it might be necessary to include additional documents to support the claim. These documents can range from medical records to evidence of damages, each playing a crucial role in substantiating the details of the incident in question. Here is a list of up to eight forms and documents that are commonly used alongside the Oregon Tort Claim form:

  • Police Report: A document that provides an official account of the incident, including details such as the time, date, location, and parties involved. It's especially vital if the claim involves a traffic accident, theft, or other incidents where law enforcement was involved.
  • Medical Records: Documents detailing any medical consultations, treatments, procedures, or prescriptions that were necessary as a result of the incident. These records help to establish the nature and extent of any injuries suffered.
  • Photographs of the Incident: Pictures that capture the scene of the incident, showing damages incurred or conditions that contributed to the incident. Photography can be powerful visual evidence that supports the claimant's depiction of events.
  • Witness Statements: Written accounts from individuals who witnessed the incident or have relevant information about it. These statements can corroborate the claimant's version of events and provide additional perspectives on the incident.
  • Property Damage Estimates: If the claim involves property damage, estimates from reputable contractors or repair shops detailing the cost of repairs are crucial. These estimates help quantify the financial impact of the damage.
  • Proof of Income Loss: Documentation such as pay stubs or employer letters that demonstrate any loss of income resulting from the incident. This is particularly important if the claimant had to miss work due to injuries.
  • Insurance Policy Information: Details of any relevant insurance policies that might cover the damages or injuries claimed. This information can be critical in determining how compensation is pursued.
  • Previous Medical History: Records of the claimant's medical history, especially those relevant to any injuries claimed as part of the tort. This can help differentiate between pre-existing conditions and those directly related to the incident.

Each of these documents serves to fortify the claim, providing a comprehensive and detailed account of the incident, its aftermath, and the resulting damages or injuries. Accurately gathered and presented, they can significantly impact the success of a tort claim in Oregon.

Similar forms

The Oregon Standard Tort Claim Form is designed for individuals to report damages or injuries potentially caused by the state or its employees. Other documents share similarities in structure, purpose, or required information with this form, reflecting its multifaceted approach to handling such claims. Each of these documents serves as a tool within various legal or administrative frameworks to address grievances, report incidents, or claim damages.

  • Insurance Claim Forms: Similar to the Oregon Tort Claim form, insurance claim forms are used to report an incident in detail to request compensation for losses. Both types of forms typically require claimant information, detailed incident descriptions, and documentation of injury or property damage.

  • Workers' Compensation Claim Forms: These are used by workers reporting workplace injuries or illnesses to obtain benefits. Like the Oregon form, workers’ compensation forms require detailed personal, incident, and injury information to process claims.

  • Vehicle Accident Report Forms: Filed after automotive accidents, these forms collect comprehensive information about the incident, similar to the Oregon form’s incident section, including a police report, location, time, and involved parties’ details.

  • Product Liability Claim Forms: Consumers use these forms to report injuries or damage caused by defective products. Both this and the Oregon form necessitate detailed descriptions of the incident, proof of damage, and an explanation of why the respondent believes the defendant is liable.

  • Medical Malpractice Claim Forms: These forms are employed to initiate legal action for medical negligence. They resemble the Oregon form's bodily injury questionnaire, emphasizing the need for detailed personal injury information and previous conditions.

  • Personal Injury Claim Forms: Used to claim compensation for injuries sustained due to another's negligence, these forms mirror the Oregon Tort Claim form in outlining the need for detailed incident and injury descriptions, witness information, and expected treatment.

  • Small Claims Court Filing Forms: Individuals seeking to resolve disputes without a lawyer can use these forms, which like the Oregon Tort Claim form, require filling in detailed claimant information, the basis of the claim, and any supporting evidence.

  • Complaint Forms for Government Oversight Bodies: Filed to report misconduct by government officials or agencies, these forms share the Oregon form’s emphasis on providing comprehensive descriptions of the incident and specifying the alleged harm or violation.

  • Property Damage Report Forms: Submitted to detail damages to property, these forms necessitate information about the extent of the damage, potential witnesses, and cause—paralleling sections of the Oregon form focused on property damage and supporting evidence.

Dos and Don'ts

When filling out the Oregon Standard Tort Claim Form, it's crucial to approach the task with precision and attention to detail. This form is a pivotal component in the process of seeking recourse for damages incurred or injuries sustained due to an incident involving a State agency in Oregon. The following guidelines can assist in ensuring that your submission is clear, comprehensive, and correctly formatted.

Do:

  • Fill out the form in Acrobat Reader: As indicated, the form should be completed using Adobe Acrobat Reader. This ensures that the document maintains its formatting and is readable upon submission.
  • Provide accurate and complete information: Accuracy is paramount. Include your full name, date of birth, and contact details. This ensures that your claim can be processed without unnecessary delays.
  • Detail the incident thoroughly: When describing the incident, be as specific as possible. Include the date, time, location, and a concise account of what occurred. Clarity here is critical for a correct assessment of your claim.
  • Include evidence: If you have a police report, photographs of damage, or any other evidence, ensure these are attached. In the case of property damage, providing two estimates can aid in the evaluation process.
  • Sign the form: Your signature certifies that the information provided is true and correct to the best of your knowledge. Unsigned forms may be returned or considered invalid.

Don't:

  • Delay submission: The form must be submitted within 180 days from the date of the loss. Late submissions might not be accepted, potentially forfeiting your claim.
  • Leave sections blank: If a section does not apply to your situation, it's advisable to note it as "N/A" rather than leaving it empty. This demonstrates that you've reviewed every section.
  • Forget about the Bodily Injury Questionnaire: If injuries were sustained, it's obligatory to fill out the bodily injury questionnaire comprehensively. Failure to provide required information can lead to delays.
  • Overlook detailing past injuries: If you have had prior injuries to the same body parts affected by the current incident, disclosing this information is critical. It provides context and assists in the accurate assessment of your claim.
  • Use unclear language or jargon: Keep descriptions and explanations clear and to the point. Avoid using legal terms or colloquial expressions that could be misunderstood.

Compliance with these dos and don'ts can facilitate a smoother claims process and increase the likelihood of a favorable outcome. Remember, completeness, accuracy, and timeliness are your allies in navigating the complexities of filing a tort claim in Oregon.

Misconceptions

When dealing with the Oregon Tort Claim form, several misconceptions often arise. Clearing these up can ensure that claimants proceed with a proper understanding of the process.

  • Misconception 1: The form is only for automobile-related claims. Despite the comprehensive nature of the form, which includes a section for bodily injuries that may appear to relate primarily to auto accidents, it's important to understand that the Oregon Standard Tort Claim Form is designed for a variety of claims against state agencies, not just those related to automobile incidents. Whether the issue is property damage or a personal injury that didn't involve a vehicle, this form is applicable.

  • Misconception 2: Submission of police reports is mandatory for all claims. The section requesting a police report may lead some to believe that a police report is always required. However, this is contingent on the nature of the incident. If a police report was made, providing it can support your claim, but there are situations, especially involving property damage or incidents without law enforcement presence, where a police report might not exist.

  • Misconception 3: You can only submit the form via email or fax. While Risk Management's contact information includes an email address and fax number, it's crucial to recognize that claimants have multiple submission options. Ensuring the form reaches the designated office can also be done by mail or potentially in person, considering the specific procedures of the office handling these claims.

  • Misconception 4: Personal injury details are unnecessary if you have medical reports. Although attaching or providing medical reports can be helpful, the Bodily Injury Questionnaire section demands direct input from the claimant regarding the nature of the injuries, medical treatment received, and other related details. This personal account is vital, even if it momentarily feels redundant alongside medical documentation.

  • Misconception 5: There's no deadline for submitting the form. A critical point where many might go wrong is the timeline for submission. According to the Oregon Revised Statutes (ORS) 30.275, there is a strict 180 days from the date of loss within which the form must be received by Risk Management. Misunderstanding this can lead to a denied claim due to a missed deadline.

Navigating through the specifics of the Oregon Standard Tort Claim Form requires attention to detail and an accurate understanding of its requirements. Addressing these misconceptions ensures individuals are better prepared to file their claims effectively.

Key takeaways

Filing an Oregon Tort Claim form is necessary for those seeking to notify the state of Oregon about a personal injury or property damage claim stemming from the actions or negligence of a state agency or its employees. Understanding the key aspects of this form is crucial for a smooth claims process. Below are eight vital takeaways to guide individuals through this task:

  • Timeliness is crucial: Claims must be submitted within 180 days from the date of the incident, as mandated by ORS 30.275. This strict deadline underscores the importance of acting promptly to avoid forfeiting the right to claim.
  • Complete details are necessary to avoid delays: The form requires comprehensive information, including claimant’s personal information, detailed incident information, and specifics regarding injuries or property damage. Omitting details can lead to processing delays.
  • Documentation enhances credibility: Providing a police report number, when applicable, and naming the state agency and employee believed to be responsible adds validity to your claim.
  • Photographs and estimates are key for property damage: Claimants are advised to include photographs of the damage along with two estimates for repair to substantiate their claims effectively.
  • Witness information can be pivotal: Including names, addresses, and phone numbers of witnesses can provide crucial support to your claim.
  • Use of Acrobat Reader for completion: Filling out the form in Acrobat Reader is recommended to ensure that the information is captured accurately and is legible, thus facilitating a smoother review process.
  • Federal law compliance: Certain questions, especially those in the Bodily Injury Questionnaire, are required under federal law. Providing this information is essential for processing the claim without undue delays.
  • Future medical treatment anticipation: The form asks whether future medical treatment is expected. This forecast helps in assessing the claim comprehensively for current and future implications of the injury.

Following these guidelines will not only streamline the process but also enhance the likelihood of a successful claim outcome. It is essential for claimants to provide as much detail and documentation as possible and to adhere to the specified timeframe.

Please rate Blank Oregon Tort Claim PDF Template Form
4.81
Incredible
16 Votes