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Tort Damage Claim

  1. Claimant Information
    Notice: Information contained in this document may be disclosed to Charleston Water System (CWS) officials, associates, and General Counsel and their staff involved in the processing of your claim.
  2. Are you a Charleston Water System customer?*
  3. Description of Claim
    Please provide a description of the claim you are making against Charleston Water System. The acceptance of this claim by Charleston Water System does not constitute an admission of legal liability on the part of CWS or any of its departments. Failure to provide adequate information may result in your claim being returned or denied.
  4. Type of claim *
    Select all that apply.
  5. Please describe the injury or damages. If medical attention was provided, provide the names and addresses of treating medical providers and medical reports and billings.
  6. Was this incident reported to law enforcement, safety or security personnel?*
    If yes, please provide a copy of the incident report in the next section.
  7. Was CWS notified of any potential risk?*
  8. Please be specific, providing any intersections or notable landmarks.
  9. Please provide the names, addresses, and telephone numbers of all persons involved in or witness to this incident.
  10. Please provide copies of any paid receipts or estimates in the next section.
  11. Supporting Documents
  12. Do you have any supporting documents, such as cost estimates, receipts, photos, an incident report, etc?
  13. How would you prefer to submit supporting documents?
  14. Below are instructions for how to submit your supporting documents.


    You will have the option to print this form and receive an email copy with this information.


    Attn: Haley Doty Vaden, Tort Claims


    Mail

    Charleston Water System

    Attn: Tort Claims

    PO Box B

    Charleston, SC 29403


    Email

    DotyVadenHC@charlestoncpw.com


    Fax

    (843) 579-6744


    Hand Delivery

    103 St. Philip Street

    Charleston, SC 29403

  15. I declare under penalty of perjury under the laws of South Carolina that the foregoing is true and correct.*
  16. Leave This Blank:

  17. This field is not part of the form submission.