Standard Tort Claim Form (Page 2 of 7) in pdf

INSTRUCTIONS FOR COMPLETING A STANDARD TORT CLAIM FORM

• Before presenting a Standard Tort Claim form, please read these instructions, the Standard Tort

Claim form, and other appropriate forms in their entirety.

• Type or print clearly in ink and sign the Standard Tort Claim 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 Standard Tort Claim form can be easily read and

understood.

• The following are examples on how to complete the Standard Tort Claim Form:

Smith, Karen Michelle

1234 College Way NW, Apt. 56, Seattle WA 98178

P0 Box 910, Seattle WA 98178

Same (or residence at the time of incident)

206-123-4567

8:00 a.m., August 9, 2008

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

provide the beginning time and the ending time in item 7

Washington, Thurston, Tumwater, Campus of South Puget Sound

Community College, Building number 22

10.

1-5, Southbound, Milepost 109, near the Martin Way Exit

11.

Smith, Thomas Arthur, 1234 College Way NW, Apt. 56, Seattle WA 98178 (360)

456-3456; Tow Truck Driver, Nisqually Towing

12.

U nk n o wn

13.

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

names, addresses, and telephone numbers that are not listed within items 11

and 12. 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 she witnessed the incident.

14.

Please describe the incident that resulted in the injury or damages,

specifically answering the questions who, what, where, when and why.

15.

If you reported this incident to law enforcement, safety, or security personnel,

please provide a copy of the report or contact information to the person you

spoke with.

16.

Please provide all of your medical providers with their names, address,

telephone numbers, and the type of treatment. If you were treated for a

personal injury, please include your medical records and bills.

17.

Attach any documents which support your claim.

18.

Please provide the dollar amount for your damages, including your time loss,

Standard Tort Claim Form Page 2

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