Cowlitz PUD Claim For Damages Form 

Pursuant to Chapter 4.96 RCW, this form is filing a tort claim against Cowlitz PUD. All of the information requested on this form is required by RCW 4.96.020 and may be subject to public disclosure. Failure to provide information may result inPursuant to Chapter 4.96 RCW, this form is filing a tort claim against Cowlitz PUD. All of the information requested on this form is required by RCW 4.96.020 and may be subject to public disclosure. Failure to provide information may result in denial of the claim. denial of the claim.  
Claims Process Information
We understand you have sustained a loss and you believe Cowlitz PUD may be responsible. If we prove to be responsible, we want to compensate you promptly and fairly. To evaluate your claim, we must determine how the incident happened, what the root cause of the incident was, and the extent of damages. Below are some frequently asked questions about submitting a claim to Cowlitz PUD.
WHAT IS THE CLAIM PROCESS? It is Cowlitz PUD’s policy to respond to claims promptly and fairly. We evaluate each claim on a case-by-case basis. The time to investigate your claim will depend on the information provided and the complexity of the incident. Our goal is to reach a decision on your claim within two weeks of its receipt. However, if there are complex issues involved, or if we need additional information, the process may take longer. WHO IS RESPONSIBLE? Generally speaking, Cowlitz PUD is responsible for damages that result from our negligence. We are not responsible for damages that we do not cause or that are the result of forces beyond our control. For example, in most instances we are not responsible for power outages or voltage fluctuations caused by weather related events or acts of natures (such as lightning, floods, earthquakes or winds), customer owned equipment failures, curtailments or outages initiated at the direction of any electric grid operator or damages caused by 3rd parties. For more information, please review our Customer Service Policy at www.cowlitzpud.org. WHAT IS YOUR RESPONSIBILITY? You have a duty to mitigate your damages, make sure that losses or expenses incurred because of an incident are not accumulating needlessly and that they are reasonable in relation to the loss. WHAT DO YOU NEED TO PROVIDE? You should retain copies of all receipts so you can provide full and accurate documentation of your losses and damages. You can help us expedite your claim by completing the claim form as thoroughly as possible, and by enclosing appropriate photographs and supporting documentation. Below are general examples:

Property Damage Personal Injury Lost Wages Misc. Losses Food Spoilage
  • Detailed repair estimate
  • Detailed repair invoices
  • Purchase receipts
  • Appraisals
  • Photographs
  • Rental receipts
  • Date of birth
  • Social Security number
  • Treatment bills
  • Release of medical records
  • Prescription receipts
  • Photographs
  • Amount of time off
  • Employer's verification
  • Payroll stubs
  • Hotel receipts
  • Restaurant receipts
  • Car rental receipts
  • Photographs
  • Itemized purchase receipts
  • Itemized list of cost and type of food
  • List to identify if items were frozen or refrigerated
  • Photographs

WHAT ARE YOUR CLAIM OPTIONS? You may wish to refer your claim to your insurance company, which may be able to reimburse you without an investigation and, depending on your coverage, may pay replacement values for damaged items. Your insurance company may then seek reimbursement from Cowlitz PUD. WHAT IF YOUR CLAIM IS DENIED? If your claim is denied, we will send a letter explaining the reason. If you are not satisfied with our decision or explanation, you may request an appeal of the decision to the District’s Appeals Officer. Or you have the right to file a court action, including a small claims action. IS THERE A TIME LIMIT ON FILING A CLAIM OR A COURT ACTION? It is always best to submit a claim as soon as possible. If you wish to file a court action, there are various time limits set by Washington State law. Generally, these are: personal injury, 3 years from the date of the injury; business interruption or economic loss with no property damage, 3 years; tangible property damage, 3 years. If you have questions regarding these limits, you should consult an attorney.

Applicant Information








Physical Address





Mailing Address




Incident Information






NOTE: If Cowlitz PUD is found liable, settlement will be based on the actual cash value of the damaged property. The measure of damages for damaged property having no market value will be based on the cost of replacement. Cowlitz PUD cannot expend public funds by which would result in betterment. Compensation would be unconstitutional under the prohibition against the Gifting of Public Funds.

Claim Process Details

Repair Item 1








Repair Item 2








Repair Item 3








Repair Item 4








Repair Item 5








Repair Item 6









Lost Wages




Medical Expenses







Witness Details

Witness 1



Witness 2



Acknowledgement
This Claim form must be signed by the Claimant a person holding a written power of attorney from the Claimant by the attorney in fact for the Claimant by an attorney admitted to practice in Washington State on the Claimant's behalf, or by a court-appointed guardian or guardian ad litem on behalf of the Claimant.
I understand that Cowlitz PUD will review all documentation in support of this claim. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.