Standard Tort Claim Form
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1
2STANDARD TORT CLAIM FORM
For Official Use Only
General Liability Claim Form #SF 210
Pursuant to Chapter 4.92 RCW, this form is for filing tort claim against Lewis
County. Information requested on this form is required by RCW 4.92.100 and
may be subject to public disclosure. Claims involving accidents with vehicles
operated by county employees should be filed on a Standard Vehicle Accident
Claim Form (#SF 138) rather than this form.
PLEASE TYPE OR PRINT IN INK
No.
Mail or deliver
Lewis County Risk Management
original claim
351 NW North St.
to:
Courthouse Basement, Room #023
Chehalis, WA 98532
CLAIMANT INFORMATION
1. Claimant's name:
_________________________________________________________________________________________________________
Last name
First
Middle
Date of birth (month, day, year)
2. Current residential address: ______________________________________________________________________________
3. Mailing address (if different): _____________________________________________________________________________
4. Residential address for six months prior to the date 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:___________a.m./p.m.
(circle one)
Month
Day
Year
8. If the incident occurred over a period of time, date of first and last occurrences:
from _____/_____/_____ Time: ____ a.m./p.m.
to ____/____/____, Time: _____a.m./p.m.
(circle one)
(circle one)
Mo
Day
Year
Mo
Day Year
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. County agency or department alleged responsible for damage/injury:
_____________________________________________________________________________________________
12. Names, addresses and telephone numbers of all persons involved in or witness to this incident:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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