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
MS 41466
Olympia, Washington 98504-1466
Fax: 360-407-8022
Email: WashingtonStateTortClaimE-Filing@des.wa.gov

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 ___________________
First ____________________
Middle __________________
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:
Home _________________________
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