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  Main Office
  1212 Court St NE
  Salem, OR 97301
  Phone: 503-763-3800
  Fax: 503-763-3900

  Claims Office
  PO Box 1469
  Lake Oswego, OR 97035
  Phone: 503-763-3875
  Fax: 503-763-3901

CIS is a member service of the League of Oregon Cities and Association of Oregon Counties


  
 
 
General Liability Claim Form
 
Use the form below to submit a general liability claim to our claims department. Required fields are in red.

Entity Name  
Entity Contact Name  
Entity Contact Phone  
Entity Contact Email (Used to send copy of submitted form)
Date of Incident  
Person Making Claim  
Address of Person Making Claim  
Phone # of Person Making Claim  
Describe Injury of Property Damage  
Location of Incident  
Date Reported to Entity  
Person Reported To
Description of Incident  
Witnesses (include contact information)
Why do you feel your entity is responsible for this incident?
 
 
 
   FILING A CLAIM
Emergency Notification Process

Claims Contact Information

WC 801 Claim Form

WC Incident Report Form

Automobile Crash Report

General Liability Claim Form

Property Claim Form 
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