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The Oregon Tort Claim form is a crucial document for individuals seeking to file a claim against a state agency for damages or injuries. This form is designed to gather essential information about the claimant, the incident, and any related damages. When completing the form, you will need to provide your personal details, including your name, address, and contact information. The form also requires specifics about the incident, such as the date, time, and location, along with a description of what occurred. If applicable, you should indicate whether a police report was filed and provide relevant details. Additionally, the form includes sections for reporting bodily injuries and property damage, along with a questionnaire to capture medical information, if necessary. It’s important to remember that claims must be submitted within 180 days from the date of the incident, so timely completion is essential. The form can be found online, and it must be filled out using Adobe Acrobat Reader for proper submission. By understanding the requirements and structure of the Oregon Tort Claim form, you can ensure that your claim is filed accurately and efficiently.

Sample - 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: [email protected]

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: [email protected]

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: [email protected]

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

Click for PDF

Form Information

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.
Contact Information Claims can be directed to Risk Management at PO Box 12009, Salem, OR 97309-0009. Phone: 503-373-7475, Fax: 503-373-7337.
Email Submission The form can be submitted via email at [email protected], but it must be completed in Acrobat Reader.
Form Accessibility The Oregon Standard Tort Claim Form is available online at the State of Oregon Risk Management website.
Required Information Claimants must provide detailed information about the incident, including the date, location, and description, as well as any witnesses.

Detailed Guide for Filling Out Oregon Tort Claim

Filling out the Oregon Tort Claim form is an essential step in addressing your concerns. Once you have completed the form, you will need to submit it to the appropriate state agency for review. Ensure that all sections are filled out accurately to avoid delays in processing your claim.

  1. Download the form: Access the Oregon Tort Claim form from the official website at this link.
  2. Open the form: Use Adobe Acrobat Reader to open the downloaded form, as it is required for proper completion.
  3. Fill in Claimant Information: Provide your full name, date of birth, current residential address, mailing address (if different), and contact numbers.
  4. Provide your email: Include your email address for communication purposes.
  5. Document the Incident: Fill in the date and time of the incident, along with the location and a detailed description of what occurred.
  6. Police Report: Indicate if a police report was filed. If yes, provide the report number and the name of the police agency.
  7. State Agency Information: Identify the state agency involved and explain why you believe they are responsible for your damages or injuries.
  8. Employee Information: If applicable, include the name of the employee involved in the incident.
  9. Bodily Injury Questionnaire: Complete this section if injuries occurred, including details about the injury, medical treatment sought, and any related costs.
  10. Property Damage: If there was property damage, describe it and include photographs and two estimates for repairs.
  11. Witness Information: List any witnesses, including their names, addresses, phone numbers, and relationship to you.
  12. Review and Sign: Carefully review all information for accuracy. Sign and date the form to declare that the information provided is true and correct.
  13. Submit the form: Send the completed form to Risk Management at PO Box 12009, Salem, OR 97309-0009, or via email at [email protected].

Obtain Answers on Oregon Tort Claim

  1. What is the Oregon Tort Claim form?

    The Oregon Tort Claim form is a document used to file a claim against a state agency for damages or injuries caused by the agency’s actions or negligence. It serves as a formal request for compensation and must be completed accurately to ensure your claim is considered.

  2. Who should use this form?

    This form is intended for individuals who have suffered damages or injuries due to the actions of a state agency in Oregon. If you believe that a state agency is responsible for your losses, you will need to fill out this form and submit it within a specified timeframe.

  3. What information is required to complete the form?

    You will need to provide several key pieces of information, including:

    • Your name, contact details, and date of birth.
    • The date, time, and location of the incident.
    • A detailed description of what happened.
    • Information about any injuries or property damage, including medical costs if applicable.
    • Details of any witnesses and their contact information.

  4. Is there a deadline for submitting the form?

    Yes, according to Oregon law (ORS 30.275), you must submit your claim within 180 days from the date of the incident. It’s crucial to adhere to this timeline to ensure your claim is valid and can be processed.

  5. What happens after I submit my claim?

    Once your claim is submitted, it will be reviewed by the Risk Management office. They will assess the details provided and determine whether the state agency is liable for your damages. You may be contacted for additional information or clarification during this process.

  6. How can I obtain the Oregon Tort Claim form?

    You can download the form directly from the State of Oregon's Risk Management website. Here is the link for your convenience: Oregon Tort Claim Form. Ensure you complete the form using Adobe Acrobat Reader for the best results.

Common mistakes

Filling out the Oregon Tort Claim form can be a complex process, and mistakes can lead to delays or even denials of claims. One common error is failing to submit the form within the required time frame. According to Oregon law, claims must be received by Risk Management within 180 days from the date of the incident. Missing this deadline can result in an automatic dismissal of the claim, regardless of its merits.

Another frequent mistake involves incomplete or inaccurate information. Claimants often neglect to provide all necessary details, such as the date, time, and location of the incident. Incomplete descriptions of the incident can hinder the review process. It is crucial to provide a clear and thorough account to ensure that the claim is understood and properly evaluated.

Many individuals also overlook the importance of documenting damages. Claimants should include photographs and estimates for property damage. Without this evidence, it becomes challenging to substantiate the claim. The absence of supporting documentation can weaken the case and may lead to a lower settlement or denial.

Additionally, some claimants fail to identify the correct state agency involved in the incident. It is essential to specify which agency is believed to be responsible for the injury or damage. A misidentified agency can result in delays, as the claim may be redirected or dismissed due to lack of jurisdiction.

Another common oversight is neglecting to provide witness information. Witnesses can play a vital role in corroborating the claimant's account of the incident. Not listing witnesses or providing incomplete contact information can diminish the credibility of the claim.

Lastly, claimants often underestimate the significance of the bodily injury questionnaire. This section requires detailed information about injuries sustained, medical treatment received, and associated costs. Incomplete answers can lead to delays in processing the claim. Providing thorough and accurate information is essential for a successful claim.

Documents used along the form

The Oregon Tort Claim form is an essential document for individuals seeking to file a claim against a state agency for damages or injuries. Along with this form, several other documents may be required to support the claim effectively. Below is a list of commonly used forms and documents that can accompany the Oregon Tort Claim form.

  • Bodily Injury Questionnaire: This form collects detailed information about any injuries sustained during the incident, including medical treatment and costs. It is crucial for establishing the extent of damages.
  • Incident Report: A document that outlines the details of the incident, including the date, time, location, and a narrative description. This report can provide context and evidence for the claim.
  • Police Report: If law enforcement was involved, a police report may be necessary. This document includes official findings and can lend credibility to the claimant's account of the incident.
  • Medical Records: These records detail any medical treatment received as a result of the incident. They are vital for substantiating claims of bodily injury and associated costs.
  • Estimates for Property Damage: If property was damaged, two estimates for repairs or replacement may be required. This helps to quantify the financial impact of the incident.
  • Witness Statements: Written accounts from witnesses can support the claimant's version of events. These statements can be crucial in corroborating details of the incident.
  • Claimant's Affidavit: A sworn statement from the claimant affirming the truthfulness of the information provided in the claim. This adds a layer of accountability to the submission.
  • Correspondence with the State Agency: Any communication with the state agency regarding the incident or claim can be helpful. This includes emails, letters, or notes from phone calls.
  • Proof of Insurance: If applicable, documentation showing any insurance coverage related to the incident can be relevant. This may include liability or health insurance information.

Submitting the Oregon Tort Claim form along with these supporting documents can enhance the chances of a successful claim. Each document serves a specific purpose in detailing the incident, substantiating damages, and providing necessary evidence to the state agency involved.

Similar forms

The Oregon Tort Claim form is essential for individuals seeking compensation for damages or injuries caused by state agencies. Several other documents share similarities with this form, primarily in their purpose and structure. Here are eight documents that resemble the Oregon Tort Claim form:

  • Personal Injury Claim Form: Like the Oregon Tort Claim, this form collects information about the claimant, the incident, and the damages incurred. It serves to initiate a claim for personal injuries sustained due to someone else's negligence.
  • Property Damage Claim Form: This document is similar in that it requires details about the property damaged, the incident, and any witnesses. It is specifically focused on claims related to property loss or damage.
  • Workers' Compensation Claim Form: This form is used by employees to report injuries sustained at work. It gathers similar information regarding the incident and the extent of injuries, aiming to secure benefits for the injured worker.
  • Auto Accident Report Form: This document is used to report accidents involving vehicles. It captures details about the incident, the parties involved, and damages, much like the Oregon Tort Claim form does for broader claims against state agencies.
  • Medical Malpractice Claim Form: This form is designed for patients seeking compensation for injuries caused by medical professionals. It requires detailed information about the incident and the resulting injuries, paralleling the structure of the Tort Claim form.
  • Liability Claim Form: Similar to the Oregon Tort Claim, this document is used to file claims against individuals or organizations for damages caused by their actions. It collects information about the claimant, the incident, and the nature of the claim.
  • Insurance Claim Form: This form is used to report losses to an insurance company. It gathers information about the incident, damages, and any witnesses, mirroring the information required in the Tort Claim form.
  • Defamation Claim Form: This document is used to initiate a claim for damages resulting from false statements that harm a person's reputation. It also requires details about the incident and damages, similar to the Tort Claim form.

Each of these forms serves a specific purpose but shares the common goal of helping individuals seek compensation for their losses or injuries. Understanding these similarities can help streamline the claims process.

Dos and Don'ts

When filling out the Oregon Tort Claim form, it is essential to approach the process with care and attention to detail. Here are some important guidelines to follow, as well as common pitfalls to avoid.

  • Do ensure accuracy. Double-check all information for correctness, including names, dates, and addresses.
  • Do provide all required details. Complete every section of the form, even if some questions seem irrelevant to your claim.
  • Do submit your claim on time. Remember that the claim must be received within 180 days from the date of the incident.
  • Do keep copies. Make sure to retain copies of the completed form and any supporting documents for your records.
  • Don’t omit any witnesses. If there were witnesses to the incident, include their information to strengthen your claim.
  • Don’t rush through the process. Take your time to fill out the form thoughtfully, as incomplete or rushed submissions can lead to delays.

By following these guidelines, you can help ensure that your claim is processed efficiently and accurately. Remember, attention to detail can make a significant difference in the outcome of your claim.

Misconceptions

Misunderstandings about the Oregon Tort Claim form can lead to confusion and delays in the claims process. Here are nine common misconceptions:

  • Misconception 1: The form can be submitted at any time.

    • In reality, claims must be submitted within 180 days from the date of the incident. Missing this deadline can result in a denial of your claim.

  • Misconception 2: You do not need to provide a police report.

    • If a police report is available, it is beneficial to include it with your claim. This documentation can support your case.

  • Misconception 3: All claims will be approved automatically.

    • Each claim is reviewed on a case-by-case basis. Approval depends on the specifics of the incident and the evidence provided.

  • Misconception 4: You can submit the form in any format.

    • The Oregon Tort Claim form must be completed in Acrobat Reader. Submitting it in another format may result in delays.

  • Misconception 5: Only physical injuries qualify for a claim.

    • Both physical injuries and property damage can be claimed. It is important to describe all damages thoroughly.

  • Misconception 6: You don’t need to include witness information.

    • Including witness details can strengthen your claim. Witnesses can provide additional evidence regarding the incident.

  • Misconception 7: The form is optional if you have insurance.

    • Even if you have insurance, you may still need to file a tort claim if the state agency is responsible for your damages.

  • Misconception 8: You can submit the claim by email.

    • The claim must be mailed to the designated address. Email submissions are not accepted for this form.

  • Misconception 9: You don’t need to provide medical information.

    • If your claim involves bodily injury, you must complete the bodily injury questionnaire. This information is critical for evaluating your claim.

Key takeaways

  • Complete the form in Acrobat Reader. This ensures compatibility and proper formatting.
  • Submit your claim within 180 days. Oregon law requires claims to be filed within this time frame from the date of loss.
  • Provide accurate personal information. Include your full name, address, and contact details to avoid delays.
  • Detail the incident clearly. Include the date, time, location, and a thorough description of what happened.
  • Include witness information. If there were witnesses, provide their names, addresses, phone numbers, and relationships to the incident.
  • Attach supporting documents. This may include police reports, photographs, and estimates for property damage.
  • Be honest in the bodily injury questionnaire. Providing truthful information about injuries and medical treatment is essential.
  • Keep a copy of your submission. Retaining a copy of the completed form and any attachments is important for your records.