Marysville School District Standard Tort Claim Form Packet (Page 2 of 5) in pdf

Instructions for Completing a Standard Tort Claim Form

 Please type or print clearly in ink.

 Provide all requested information and any available documents or evidence supporting your claim, such

as medical records or bills, photographs, or receipts for property damage.

 If the requested information cannot be supplied in the space provided, please use additional pages so

your claim form can be easily read and understood.

 The following are examples of how to complete the Standard Tort Claim Form:

1. Doe, Jane Ann

2. 1234 State Avenue, Marysville WA 98270

3. PO Box 123, Marysville WA 98270

4. Same (or residence at time of incident)

5. 360 123 4567

or Not Applicable

7. August 9, 2010

8:00 am

8. If the incident that caused the damages occurred over a period of time, please provide the

beginning time and the ending time in # 8.

9. Washington / Snohomish County / Marysville / name of school or site, room or space (e.g. gym)

10. State Avenue / specify milepost, if known / intersection of State Avenue and 10

St NE

11. Marysville School District No. 25

12. Smith, John – 1234 Columbia Avenue, Apt 3B, Marysville WA 98270 / 360 653 1234

13. List all names and title, if known

14. List all other witnesses having knowledge of the incident in question, with their names,

addresses and telephone numbers that are not listed within Items 12 and 13. 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, telephone number and indicate that she

witnessed the incident.

15. Please describe the incident that resulted in the injury or damages, specifically answering the

questions Who – What – Where – When – Why

16. If you or others reported this incident to law enforcement or security personnel, please provide

a copy of the report or contact information.]

17. Please provide all of your medical providers, including their names, addresses and telephone

numbers, if applicable. You will be asked to provide a medical release statement.

 If you are filing a personal injury claim, please sign and attach the Medical Release (attached).

 If your claim involves a motor vehicle accident, please complete, sign, and attach the vehicle accident

form (attached).

Sign the standard Tort claim form and date.

Mail or present the Standard Tort claim to:

Marysville School District

Attn: Office of Superintendent

4220 80

St NE

Marysville WA 98270

(Business hours: Monday – Friday 7:30 am – 4:30 pm)

Rev 8/21/15

Marysville School District Standard Tort Claim Form Packet Page 2

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