AWC Tort Claim Form-writeableTort claim form:
Claim for damages
R I S K
MANAGEMENT
S E R V I C E Entityname:
AGENCY
Pursuant to RCW Chapter 4.96, this form is for submitting a tort claim against the entity name above.
Information requested on this form is required by RCW 4.96.020 and may be subject to public disclosure.
Claim forms cannot be submitted electronically (via e-mail or fax).
Please attach documents which support the claim's allegations.
Mail or deliver original claim to:
Claimant information
Claimant's name:
First name
Date of birth
Current residential address:
Mailing address (if different):
Telephone number:
Email address:
Middle
Are you represented by an attorney? Yes FINo
Attorney name:
Attorney firm:
Mailing address:
Phone:
Email:
Last name
Tort claim form Revised 08/22
Incident information
Date of the incident: Time:
(mm/dd/yyyy)
If the incident occurred over a period of time, date of first and last occurrences:
From: I To:
(mm/dd/yyyy) Time am pm
Where did the incident occur?
Name of street or road:
Nearest intersection:
Describe what happened (attach additional pages if need):
How was this municipality involved?
Were you injured? ❑ Yes ❑ No
Describe any damage to your property or injuries:
(mm/dd/yyyy)
Was your vehicle involved or damaged? Yes ❑ No
am pm
Time am pm
License late:
Make:
Model:
Year:
Registered owner name:
Insurance company:
Insurance policy number:
Tort claim form Revised 08/22
Witnesses and others involved:
Name
Phone/Email
How was this person involved?
1.
2.
3.
I am claiming damages in the amount of $ If damages are unknown, provide an estimate if possible.
Please attach documents which support the claim's allegations.
This claim form must be signed by the claimant, a person holding a written power of attorney from claimant, an
attorney for the claimant, by an attorney admitted practicing in Washington state of behalf of the claimant, or by
a court -approved guardian or guardian ad litem on behalf of the claimant.
I declare under penalty of perjury under the laws of Washington state that the foregoing is true and correct.
Printed name of person who completed the form:
Signature of claimant/Individual who completed the form:
Date and city and state:
Tort claim form Revised 08/22