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

Standard Tort Claim Form Page 7

13. Names address and telephone numbers of all individuals not already identified in #11 and #12 above

that have knowledge regarding the liability issues involved in this incident, or knowledge of the

Claimant's resulting damages. Please include a brief description as to the nature and extent of each

person's knowledge. Attach additional sheets if necessary.

14. Describe the cause of the injury or damages. Explain the extent of property loss or medical,

physical or mental injuries. Attach additional sheets if necessary.

15. Has this incident been reported to law enforcement, safety or security personnel? If so, when and

to whom?

16. Names, address and telephone numbers of treating medical providers. Attach copies of all

medical reports and billings.

17. Please attach documents which support the claim's allegations.

18. I claim damages from PHD _______________y in the sum of $_________________.

This Standard Tort Claim Form must be signed by the Claimant, a person holding a written power of

attorney from the Claimant, by the attorney-in-fact for the Claimant, by an attorney admitted to practice

in the State of Washington on the Claimant's behalf, or by a court-appointed guardian or guardian ad litem

on behalf of the Claimant.

I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true

and correct.

Signature of Claimant

Date and place (residential address, city and county)

Standard Tort Claim Form Page 7