Fillable Washington State - Form SF210 Tort Claim Form

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Washington State - Form SF210 Tort Claim Form

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The Washington State - Form SF210 Tort Claim Form form is 16 pages long and contains:

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  • 115 check-boxes
  • 155 other fields

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File type: PDF

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December 2018
Washington State Tort Claim Form Packet
Please carefully read all of the information in this packet before completing and presenting your
Washington State Tort Claim. Tort claims are subject to public disclosure pursuant to RCW 42.56.
NOTE: all documents received by the Office of Risk Management (ORM) become the property of ORM
and will not be returned. Please keep a copy for your records and do not send original attachments if
you may want them returned.
Presenting a Standard Tort Claim Form
RCW 4.92.100 requires citizens to present the Standard Tort Claim form with the Office of Risk
Management (ORM). The law also requires ORM to post on its website the Standard Tort Claim form
with instructions. In compliance with these requirements and for the convenience of citizens, ORM
developed the Washington State Tort Claim Form Packet.
Documents Contained in the Standard Tort Claim Form Packet
1. Instructions for completing the Standard Washington State Tort Claim Form
2. Standard Washington State Tort Claim Form (SF 210)
3. Medical Authorization (only for tort claims involving bodily injury)
4. Vehicle Collision Form (only for tort claims involving vehicle accidents/collisions)
5. Mandatory Medicare Beneficiary Reporting Form
Legal Requirements for Presenting Standard Tort Claim Forms
In order to verify the claim and additional supporting information, the law requires that the Standard
Tort Claim form be signed by:
• Claimant; or
• Person holding a written power of attorney from the Claimant; or
• Attorney in fact for the Claimant; or
• Attorney admitted to practice in Washington state on the Claimant’s behalf; or
• A court-approved guardian or guardian ad litem on behalf of the Claimant
Present in Person, Mail, Fax or Email the Washington State Tort Claim Form & Supporting Documents to:
Department of Enterprise Services
Office of Risk Management
1500 Jefferson Street SE, MS 41466
Olympia, WA 98504-1466
Phone (360) 407-9199
Fax (360) 507-9251
Email: Claims@des.wa.gov
Business Hours: Monday-Friday, 8:00 a.m. to 5:00 p.m. Closed on weekends and official state holidays.
December 2018
INSTRUCTIONS FOR COMPLETING A TORT CLAIM FORM
General Liability Claim Form #SF 210
Before filing a Tort Claim, please read these instructions, the Tort Claim form and other appropriate
forms in their entirety.
Type or print clearly in ink and sign the Tort Claim form. Do not staple or tape documents. Do not
put in claim form in binders or add divider tabs as all documents must be scanned.
Provide all requested information and any available documents or evidence supporting your claim,
such as medical records or bills for personal injuries, photographs, proof of ownership for property
damages, receipts for property value, etc.
If the requested information cannot be supplied in the space provided, please use additional blank
sheets so your claim can be easily read and understood.
The following are examples on how to complete the Tort Claim Form #SF 210:
1) Smith, Karen Michelle – 02/20/1965
2) #809234 (for use by Department of Corrections inmates only)
3) 1234 College Way NW, Apt. 56, Seattle WA 98178
4) PO Box 910, Seattle WA 98178
5) Same (or residence at the time of incident)
6) (206) 123-4567 – (206) 987-6543
7) KMSmith@hotmail.com
8) 8/9/2010 8:00 a.m.,
9) If the incident that caused the damages occurred over a period of time, please provide the
beginning time and the ending time in item 8.
10) Washington, Thurston, Tumwater, Campus of South Puget Sound Community College,
Building number 22.
11) I-5, Southbound, Milepost 109, near the Martin Way Exit
12) Washington State Department of Transportation, Highway
13) Smith, Thomas Arthur, 1234 College Way NW, Apt. 56, Seattle WA 98178 (360) 456-3456;
Tow Truck Driver, Nisqually Towing
14) Unknown
15) List all other witnesses having knowledge of the incident in question, with their names,
addresses, and telephone numbers that are not listed within items 13 and 14. Also include a
description of their knowledge. For example, if your sister was with you when the alleged
incident occurred, please include her name, address, telephone number, and indicate she
witnessed the incident.
16) Please describe the incident that resulted in the injury or damages, specifically answering the
questions who, what, where, when and why.
17) If you reported this incident to law enforcement, safety, or security personnel, please provide a
copy of the report or contact information to the person you spoke with.
18) Please provide all of your medical providers with their names, address, telephone numbers, and
the type of treatment. If you were treated for a personal injury, please include your medical
records and bills.
19) Please attach any additional documents that support your claim.
20) Please provide the dollar amount for your damages, including your time loss, medical costs,
property damage loss, etc. This amount should represent your opinion of total compensation.
If you are filing a personal injury claim, please sign and attach the Medical Release.
If your claim involves a motor vehicle accident, please complete, sign, and attach the vehicle
accident form.
P
LEASE TYPE OR PRINT CLEARLY IN INK
M
ail or deliver Department of Enterprise Services
original claim to Office of Risk Management
1500 Jefferson Street SE, MS 41466
Olympia, Washington 98504-1466
Phone: (360) 407-9199
Fax: (360) 507-9251
Email: Claims@des.wa.gov
B
usiness 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: Time: □ a.m. □ p.m. (check one)
(mm/dd/yyyy)
9. If the incident occurred over a period of time, date of first and last occurrences:
from Time:
□ a.m. □ p.m.
(mm/dd/yyyy) (mm/dd/yyyy)
to Time: □ a.m. □ p.m.
(mm/dd/yyyy) (mm/dd/yyyy)
10. Location of incident:
State and county City, if applicable Place where occurred
WASHINGTON STATE TORT CLAIM FORM
General Liability Claim Form #SF 210
P
ursuant 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 is subject to public
disclosure pursuant to RCW 42.56.
For Official Use Only
11. If the incident occurred on a street or highway:
Name of street or highway Milepost number At the intersection with or
nearest intersecting street
12. State agency
or department you believe is responsible for damage/injury:
13. Names and teleph
one numbers of all persons involved in or witness to this incident:
14.
Names and telephone numbers of all state employees having knowledge about this incident:
15. Names and telephone numbers of all individuals not already identified in #13 and #14 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.
16. Describe
how the state of Washington caused your injuries or damages (if your injuries or damages
were not caused by the State, do not use this form. You must file your claim against the
correct entity). Explain the extent of property loss or medical, physical or mental injuries. Attach
additional sheets if necessary.
17. Has this
incident been reported to law enforcement, safety or security personnel? If so, when and to
whom? Please attach a copy of the report or contact information.
18. Names, addresses and telephone numbers of treating medical providers. Submit copies of all medical
reports and billings.
19. Please attach
documents which support the allegations of the claim.
20. I claim damages f
rom the state of Washington in the sum of $___________.
This Claim f
orm must be signed by one of the following (check appropriate box).
□ Claimant
□ Person holding a written power of attorney from the Claimant
□ Attorney in fact for the Claimant
□ Attorney admitted to practice in Washington State on the Claimant's behalf
□ Court-approved guardian or guardian ad litem on behalf of the Claimant
I declare under pen
alty 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)
Or
Signature of Representative Date and place (residential address, city and county)
Print Name of Representative Bar Number (if applicable)
1
Authorization for Release of Protected Health Information (PHI)
to
Department of Enterprise Services, Office of Risk Management
N
ame: ________________________________________________________
(Last, First, Middle Initial or Middle Name)
D
ate of Birth: Month _____ Day ____ Year _________
I
hereby authorize disclosure of my protected health information to the Department of Enterprise
Services, Office of Risk Management (Risk Management) for purposes of processing my claim for
damages filed with the state of Washington.
I
understand that by signing this document, I authorize the release of the following information:
C
omplete medical record for all services, including history and physical exam; progress notes; x-ray
reports; inpatient admissions; operative notes; physical or other therapy; laboratory and other test
reports; physician and physician assistant orders; nursing notes; and all other records and references
designated by the provider as part of its medical record.
HIV Test Results and medical information related to HIV testing or treatment
P
sychiatric, mental and behavioral health records, including treatment notes, assessments, testing
documents and results, and medical records related to mental health diagnosis and treatment
A
lcohol assessment, testing, referral or treatment records
A
ll other chemical dependency assessment of treatment records
P
harmacy prescriptions and reports
A
ll letters and memos received or sent, including electronic mail, referencing my treatment,
compliance with treatment and any other subject related to my medical treatment
I
nformation related to alleged sexual assault or sexually transmitted disease, including test results
U
rgent care, outpatient or other clinic visit information
Gynecological and/or obstetrical information
A
ll client records generated for or by governmental programs of which I am a client. Identify the
program(s) and agency: ___________________________________________________.
F
inancial records related to my care and treatment
2
I understand the following: (PLEASE READ AND INITIAL ALL STATEMENTS)
_____ I understand that my records are protected under HIPAA/PHI regulations (federal law) and the
Washington State Health Care Information Act (RCW 70.02).
_____ I understand that my health information may be subject to re-disclosure by Risk Management and
not protected for purposes of evaluating and investigating the claim I have filed with the state of
Washington.
_____ I understand that the specific information to be disclosed in my medical record may include
information regarding alcohol, drug or other controlled substance use, counseling referrals and/or
a history of testing or treatment of acquired immune deficiency syndrome.
_____ I understand that I may revoke this authorization at any time by notifying Risk Management in
writing, and that the revocation will be effective as of the date Risk Management receives it. Any
records obtained pursuant to this Authorization for Release of PHI prior to the revocation will be
deemed authorized by me for release.
_____ I understand that this Authorization for Release will expire 90 days from the date I sign it. I can
also authorize a different time frame for this release to be valid. This permission is valid until my
claim is resolved or closed by ORM.
A Photostat of this Authorization carries the same authority as the original for purposes of releasing my
records to Risk Management.
Signature of Authorizing Individual:
____________________________________________________________________________
Date of Signature: _____________________________________________________________
Telephone number: ____________________________________________________________
Witness (where patient is over 13 and signing the release):
____________________________________________________________________________
Where the signer is not the subject of the records:
I am authorized to sign this because I am the (attach proof of authority):
Parent of minor
Legal Guardian
Personal Representative
Other
________________________________________________________________
To the Provider or Records Custodian:
Please send legible copies of all records to:
Department of Enterprise Services
Office of Risk Management
1500 Jefferson Street SE
Olympia, WA 98504-1466
Fax: 360-507-9251
Email: Claims@des.wa.gov
Initials
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MMSEA REPORTING COMPLIANCE DECLARATION
The Centers for Medicare & Medicaid Services (CMS) is the federal agency that oversees the Medicare program. Many Medicare beneficiaries have
other insurance in addition to their Medicare benefits. Sometimes, Medicare is supposed to pay after the other insurance. However, if certain other
insurance delays payment, Medicare may make a “conditional payment” so as not to inconvenience the beneficiary and recover after the insurance
pays.
Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA), a federal law that became effective January 1, 2009, requires
that liability insurers (including self-insurers like the state of Washington), no-fault insurers, and workers’ compensation plans report specific
information about Medicare beneficiaries who have other insurance coverage. This reporting is to assist CMS and other insurance plans to properly
coordinate payment of benefits among plans so that your claims are paid promptly and correctly. Please answer the questions below so that we may
comply with this law.
if you have, or have ever had, a similar Medicare card.
Section I
Are you presently, or have you ever been enrolled in Medicare Part A or Part B?
Yes
No
If yes, please complete the following. If no, proceed to Section II.
Full Name: (Please print the name exactly as it appears on the SSN or Medicare card if available.)
Medicare Claim Number:
Date of Birth(Mo/Day/Year)
Social Security Number: (If Medicare Claim Number is Unavailable)
-
-
Sex
Female
Male
Section II
I understand that the information requested is to assist the requesting insurance arrangement to accurately coordinate benefits with Medicare and to
meet its mandatory reporting obligations under Medicare law.
Claim Number
Name of Person Completing This Form If Claimant is Unable (Please Print)
Date
If you have completed Sections I and II above, stop here. If you are refusing to provide the information requested in Sections I and II, proceed to
Section III.
Section III
Claim Number
For the reason(s) listed below, I have not provided the information requested. I understand that if I am a Medicare beneficiary and I do not provide
the requested information, I may be violating obligations as a beneficiary to assist Medicare in coordinating benefits to pay my claims correctly and
promptly.
Reason(s) for Refusal to Provide Requested Information:
Date
VEHICLE COLLISION FORM
PLEASE TYPE OR PRINT IN INK
SF 138 (July 2009)
CLAIMANT AND
INCIDENT
INFORMATION
YOUR VEHICLE
INFORMATION (VEHICLE #1)
OTHER VEHICLE
INFORMATION
(VEHICLE #2)
OTHER NON-
VEHICLE
DAMAGE
INJURED PARTIES WITNESSES
DATE OF ACCIDENT(mm/dd/yyyy) TIME
AM
CLAIMANT'S NA
ME
CURRENT STREET (RESIDENCE) ADDRESS CITY STATE ZIP
(RESIDENCE) STREET ADDRESS FOR SIX MONTHS PRIOR TO THE ACCIDENT ZIPSTATECITY
INTERSECTION OR NEAREST STREET/ROADSTREET OR HW Y MILEPOST NO.
YEAR MAKE MODEL LICENSE PLATE NO. WHEN?
NAME OF VEHICLE OWNER ADDRESS CITY HOME AND W ORK PHONE
NAME OF DRIVER ADDRESS CITY HOME AND W ORK PHONE
DRIVER'S LICENSE NUMBER STATE OF ISSUANCE
DESCRIBE DAMAGE YOUR INSURANCE COMPANY AND POLICY NO.
YEAR MAKE MODEL LICENSE PLATE NO.
WHERE CAN CAR BE SEEN?
STATE AGENCY, IF KNOWN
NAME OF OWNER ADDRESS CITY PHONE
NAME OF DRIVER ADDRESS CITY PHONE
DESCRIBE DAMAGE ESTIMATE
$
NAME OF OWNER ADDRESS CITY PHONE
WAS OTHER (NON-VEHICLE) PROPERTY DAMAGED? IF SO, DESCRIBE WHAT TYPE OF PROPERTY WAS DAMAGED.
ESTIMATEDESCRIBE DAMAGE
NAME ADDRESS PHONE INJURY PED OTH
NAME (ATTACH ADDITIONAL SHEETS IF NECESSARY) ADDRESS CITY
HOME
WORK
HOME
WORK
HOME
WOR
K
HOME
WORK
HOME
WORK
PHONE
HOME
WORK
HOME
WORK
HOME
WORK
PM
NAME OF OWNER
DATE OF EXPIRATION
(A SEPARATE FORM MUST BE COMPLETED FOR EACH CLAIMANT)
CITY PHONEADDRESS
HOME PHONE
WORK PHONE
/
State/County/City (if applicable) where occurred
EMAIL
Please attach this form to your standard tort claim form, if the claim involves a vehicle collision.
AGE VEH 1 VEH 2 VEH 3
$
ESTIMATE
$
COMPLETE ALL DETAILS
Describe conduct and circumstances causing injury or damages and explain the extent of medical, physical or mental injuries. Please
identify name, address, and telephone number of treating physicians and other medical providers. Please attach property damage
estimates and/or all medical bills in support of your claim. If necessary, attach additional pages containing information in this format.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Straight Road Hillcrest One Lane
Curve – R or L Uphill One and One-Half Lane
Level Downhill Two Lane or Four Lane
LIGHT CONDITIONS
(CHECK ONE)
TRAFFIC CONTROL
TYPE OF ROAD
(CHECK ONE OR MORE)
ROAD SURFACE
(CHECK ONE)
WEATHER
(CHECK ONE)
VEHICLE CONDITION
(CHECK ONE OR MORE)
1 DAYLIGHT
2 DAWN
3 DUSK
4 DARK STREET
LIGHTS ON
5 DARK STREET
LIGHTS OFF
6 DARK NO
STREET LIGHTS
7 OTHER
(SPECIFY)
VEHICLE
NO. 1 NO. 2
1
2
3
4
5
6
7
8
9
SIGNALS
STOP
F
LASHING
FLASHING
RED
AMBER
RR
OFFICER/
FLAGMAN
YIELD
NO
OTHER
VEHICLE
NO. 1 NO. 2
1
2
3
4
5
6
1
2
3
ONE WAY
TWO WAY
REVERSIBLE
ROAD
INTER-
LOOP RAMP
ALLEY
TWO WAY-
SEPARATE
D
DIVIDED
UNDIVIDED
VEHICLE
NO. 1 NO. 2
1
2
3
4
5
6
DEFECTIVE
BRAKES
DEFECTIVE
HEADLIGHTS
DEFECTIVE
REAR LIG
HTS
TIRES WORN
PUNCTURED
OR BLOWN
OTHER
(SPECIFY)
VEHICLE
NO. 1 NO. 2
1
2
3
4
5
DRY
WET
SNOW
ICE
OTHER
(SPECIFY)
1
2
3
4
5
CLEAR, CLOUDY &
OVE
RCAST
RAINING
SNOWING
FOG
OTHER
(SPECIFY)
TIRES
CHANGE
LEFT TURN
LANES
SIGN
SIGN
TRAFFIC
CONTROL
SIGNAL
NAME OF INVESTIGATING POLICE AGENCY:
INVESTIGATING AGENCY REPORT NO.
A separate claim form should be submi
tted for each claimant
.
This information is
being provided to aid in resolving the claim
.
I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
________________________________________________
_____________________________________________________
Sign
ature of Claimant
Date and Pl
ace (residential address, city and county)
Mark Damaged Areas
L
E
F
T
R
I
G
H
T
L
E
F
T
R
I
G
H
T
Indicate points of compass
N. E. S. W.
Street
Center
Sidewalk
Sidewalk
Show on diagram position
of each car, vehicle or
injured person, indicating
by arrow direction of each.
If street or view was obstructed
in any way, indicate where and
how; also indicate any street car
or tracks and traffic signals or
signs.
IMPORTANT
VEH.
1
VEH.
2
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Washington State - Form SF210 Tort Claim Form

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Completed 26 May 2020

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