Standard Tort Claim Form Page 6
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7Standard Tort Claim Form
General Liability Claim Form
Pursuant to Chapter 4.92 RCW, this form is for filing a tort claim against
For Official Use only
__________________________. Some of the information on this form
is required by RCW 4.92.100 and may be subject to public disclosure.
Pursuant to law, Standard Tort Claim forms cannot be submitted
electronically (via e-mail or fax).
PLEASE TYPE OR PRINT IN INK
No.
Mail or deliver original claim to:
Business Hours are .
CLAIMANT INFORMATION:
1. Claimants name: ___________________________________________________________________
Last name
First
Middle
Date of Birth (mm/dd/yyyy)
2 Current residential address: ___________________________________________________________
3. Mailing address (if different) ____________________________________________________________
4. Residential address at the time of the incident (if different from current address):
___________________________________________________________________________________
5. Claimant's daytime telephone number:
Home:_____-_____-_______ Business: ____-____-_______
6. Claimant's e-mail address: ____________________________________________________________
INCIDENT INFORMATION:
7. Date of the incident: _____/_____/________
Time: __________
AM PM
(circle one)
(mm/dd/yyyy)
8. If the incident occurred over a period of time, date of first and last occurrences:
from ____/____/______ Time: _____
AM PM to____/____/______ Time _____ AM PM
(circle one)
(circle one)
9. Location of incident: _________________________________________________________________
State and County
City (if applicable)
Place where occurred
10. If the incident occurred on a street or highway:
___________________________________________________________________________________
Name of street or highway
Milepost Number
At the intersection with or nearest intersecting street
11. Names, addresses and telephone numbers of all persons involved in or witness to this incident:
__________________________ ____-____-______ _______________________ ____-____-______
Name
Number
Name
Number
__________________________ ____-____-______ _______________________ ____-____-______
Name
Number
Name
Number
__________________________ ____-____-______ _______________________ ____-____-______
Name
Number
Name
Number
12. Names, addresses and telephone numbers of Hospital employees having knowledge of this incident.
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