For Official Use Only
STANDARD TORT CLAIM FORM
General Liability Claim Form #SF 210
Pursuant to Chapter 4.92 RCW, this form is for filing a tort claim against the state of Washington. Some of the information requested on this form is required by RCW 4.92.100 and may be subject to public disclosure.
PLEASE TYPE OR PRINT CLEARLY IN INK
Mail or deliver original claim to
Department of Enterprise Services
Office of Risk Management
1500 Jefferson Street SE
Olympia, Washington 98504-1466
Business Hours: Monday - Friday 8:00 a.m. - 5:00 p.m.
Closed on weekends and official state holidays.
1. Claimant's name:
Last name ___________________
Date of birth (mm/dd/yyyy) ______________
2. Inmate DOC number (if applicable): _________________
3. Current residential address: _______________________________________
4. Mailing address (if different): _____________________________________
5. Residential address at the time of the incident:___________________________________________
(if different from current address)
6. Claimant's daytime telephone number:
Business or Cell ___________________
7. Claimant's e-mail address: ____________________________________
8. Date of the incident: _________________(mm/dd/yyyy) Time: _________  a.m.  p.m. (check one)
9. If the incident occurred over a period of time, date of first and last occurrences:
from _______________________ (mm/dd/yyyy) Time: _________________  a.m.  p.m.
to _________________________ (mm/dd/yyyy) Time: _________________  a.m.  p.m.
10. Location of incident: Washington, within it's county & cities of Department facilities
State and county City, if applicable Place where occurred
2019 jun 11
2018 dec 27
2018 dec 12
2018 dec 7
2018 nov 1
2018 sep 19