Oregon Form Tort Claim PDF Details

When individuals in Oregon find themselves needing to report a claim against a state agency due to injury, damage, or loss, the Oregon Standard Tort Claim Form serves as their first step. Managed by the state's Risk Management Department, this form requires detailed information about the incident, including claimant information, specifics about the incident, and any damages or injuries that occurred. The form, designed to be filled out in Acrobat Reader for accuracy and clarity, is accessible online, making it easier for claimants to start their process. It even includes sections for witness details, a bodily injury questionnaire which is mandatory under federal law to fill, especially concerning claims that may involve Medicare or Medicaid services. Furthermore, the form obliges claimants to provide evidence of the damage in the form of photographs and repair estimates, if applicable, ensuring that all claims are substantiated. The necessity of submitting this form within 180 days from the date of the incident is underscored by Oregon law, emphasizing the importance of timely submission in the claims process. By offering a standardized way to report and detail claims, Oregon is streamlining the resolution process for both the claimants and the state agencies involved, with the ultimate goal of fair and efficient handling of all claims.

QuestionAnswer
Form NameOregon Form Tort Claim
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesoregon form claim, ors tort claim notice, oregon tort claims notice, chl 70 texas form b

Form Preview Example

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

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This form requires specific details; to ensure accuracy, please adhere to the subsequent steps:

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Stage number 1 in filling in oregon form tort

2. After completing the previous part, head on to the subsequent step and fill out the essential particulars in all these blanks - y Name of State agency involved, Name of employee if applicable, If injuries occurred please, If property damage occurred, s e g a m a D, and s Witness name address phone.

oregon form tort conclusion process shown (part 2)

3. Completing Last Name, Date of Birth mmddyyyy, First name, Gender cidM cidF, Middle initial, Is this related to an auto, If yes where were you seated in, cidDriver cidFront right passenger, Seatbelt used cidYes cidNo, What kind cidLap cid Shoulder cid, Did the airbag deploy cidYes cid, e r i, Describe your injury, a n n o i t s e u Q y r u n, and l i is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

oregon form tort completion process described (step 3)

4. This next section requires some additional information. Ensure you complete all the necessary fields - Is future treatment expected, If yes explain, Do you have any prior injuries to, If yes explain, Any other information you would, Page of, and Revised Form No DASRM Standard - to proceed further in your process!

Simple tips to complete oregon form tort part 4

5. Because you approach the finalization of your document, you will find several extra things to do. Particularly, Additional information, Per ORS Risk Management must, Signature of claimant, and Date should be filled out.

Stage no. 5 for completing oregon form tort

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