Damage Claim Form Instructions

The completed form must be notarized. There are notaries at City Hall that can notarize your claim form; however, you must have picture identification and sign the form in the presence of the notary. You can use an outside notary as well. Please submit your completed claim form to the Centralia City Clerk at:
118 W Maple Street
2nd floor
Centralia, WA 98531 

or mail to:
P. O. Box 609
118 W Maple Street
Centralia, WA 98531

Before filing a claim, please read these instructions and the claim form in its entirety.

  • Type or print clearly in ink and sign the form.
  • Provide all requested information and any available documents or evidence supporting your claim, such as medical records or bills for personal injuries, photographs, proof of ownership for property damages, receipts for property value, etc.
  • If the requested information cannot be supplied in the space provided, please use additional blank sheets so your claim can be easily read and understood.
  • List all other witnesses having knowledge of the incident in question, including their names, addresses, and telephone numbers. Also, include a description of their knowledge. For example, if your sister was with you when the alleged incident occurred, please include her name, address, and telephone number, and indicate she witnessed the incident.
  • Please provide the names, addresses, and telephone numbers of all your medical providers and the type of treatment provided. If you were treated for a personal injury, please include your medical records and bills.
  • Please describe the incident that resulted in the injury or damages, specifically answering the questions who, what, where, when and why.
  • If you reported this incident to law enforcement, safety, or security personnel, please provide a copy of the report or contact information for the person with whom you spoke.
  • Please provide the dollar amount of your damages, including your time loss, medical costs, property damage loss, etc. This amount should represent your opinion of total compensation.
  • If your claim involves a motor vehicle accident, please complete, sign, and attach the vehicle accident form.