STANDARD VEHICLE ACCIDENT TORT CLAIM FORM
PLEASE TYPE OR PRINT IN INK
For Official Use Only
Pursuant to RCW 4.92, this form is provided for your convenience when filing a tort claim against the State of Washington involving an accident with a vehicle being operated by a state employee.
Mail or deliver original claim in duplicate to:
Office of Financial Management Risk Management Division 300 General Administration Building Post Office Box 41027, MS: 41027 Olympia, Washington 98504-1027 This Claim Form cannot be submitted electronically (via e-mail or fax)
(A SEPAR ATE FORM M UST BE C OM PLETED FOR EACH CLAIMANT) DATE OF ACCIDENT TIME AM PM
CLAIMANT'S N AME
CLAIMANT AND INCIDENT INFORMATION
CURRENT STREET (RESIDENCE) ADDRESS
CITY
STATE
ZIP
PHONE
HOME W ORK
(RESIDENC E) STREET ADDRESS FOR SIX MONTHS PRIOR TO THE ACCIDENT
CITY
STATE
ZIP
EMAIL
/ State/County/City (if applicable) where occurred
STREET OR HW Y
MILEPOST NO.
INTERSECTION OR NEAR EST STREET/ROAD
YEAR
MAKE
MODEL
LICENSE PLATE NO.
W HERE CAN CAR BE SEEN ?
W HEN?
YOUR VEHICLE INFORMATION (VEHICLE #1)
NAME OF VEHIC LE OW NER
ADDRESS
CITY
HOME AND W ORK PHONE
NAME OF DR IVER
ADDRESS
CITY
HOME AND W ORK PHONE
DRIVER'S LICENSE NU MBER
STATE OF ISSUANC E
DATE OF EXPIRATION
DESCRIBE DAMAGE
ESTIMATE
$
MODEL LICENSE PLATE NO.
YOUR INSUR ANCE CO MPAN Y AND POLIC Y NO.
YEAR
MAKE
STATE AGENCY, IF KNOW N
OTHER VEHICLE INFORMATION (VEHICLE #2)
NAME OF OW NER
ADDRESS
CITY
PHONE
NAME OF DR IVER
ADDRESS
CITY
PHONE
DESCRIBE DAMAGE
ESTIMATE
$
W AS OTHER (NON-VEHIC LE) PROPERT Y D AMAGED? IF SO, D ESCRIBE W HAT TYPE O F PROPERTY W AS DAMAGED.
OTHER NONVEHICLE DAMAGE
NAME OF OW NER
ADDRESS
CITY
PHONE
DESCRIBE DAMAGE
ESTIMATE
$
ADDRESS HOME W ORK PHONE INJURY AGE VEH 1 VEH 2
NAME
VEH 3
PED
OTH
INJURED PARTIES
HOME W ORK HOME W ORK HOME W ORK HOME W ORK NAME (ATTACH ADDITIONAL SHEETS IF NEC ESSAR Y) ADDRESS CITY PHONE HOME W ORK HOME W ORK HOME W ORK
SF 138 (Rev Jun-04)
WITNESSES
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 Curve – R or L Level
Show on diagram position of each car, vehicle or injured person, indicating by arrow direction of each.
Hillcrest Uphill Downhill
One Lane One and One-Half Lane Two Lane or Four Lane
Mark Damaged Areas
R I G H T
VEH. 1
L E F T R I G H T
Sidewalk Street Center Sidewalk
IMPORTANT
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.
VEH. 2
Indicate points of compass N. E. S. W.
TYPE OF ROAD (CHECK ONE OR MORE) VEHICLE NO. 1 NO. 2 SIGNALS STOP SIGN FLASHING RED FLASHING AMBER RR SIGNAL OFFICER/ FLAGMAN YIELD SIGN NO TRAFFIC CONTROL OTHER 1 2 3 4 ONE WAY TWO WAY REVERSIBLE ROAD INTERCHANGE LOOP RAMP ALLEY TWO WAYLEFT TURN LANES SEPARATED DIVIDED UNDIVIDED VEHICLE CONDITION (CHECK ONE OR MORE) VEHICLE NO. 1 NO. 2 1 2 3 4 5 DEFECTIVE BRAKES DEFECTIVE HEADLIGHTS DEFECTIVE REAR LIGHTS TIRES WORN PUNCTURED OR BLOWN TIRES OTHER (SPECIFY) ROAD SURFACE (CHECK ONE) VEHICLE NO. 1 NO. 2 1 2 3 4 5 DRY 2 WET SNOW ICE OTHER (SPECIFY) 3 SNOWING 1 WEATHER (CHECK ONE) CLEAR, CLOUDY & OVERCAST RAINING
L E F T
LIGHT CONDITIONS (CHECK ONE) 1 2 3 4 5 6 7 DAYLIGHT DAWN DUSK DARK STREET LIGHTS ON DARK STREET LIGHTS OFF DARK NO STREET LIGHTS OTHER (SPECIFY)
TRAFFIC CONTROL VEHICLE NO. 1 NO. 2 1 2 3 4 5 6 7 8 9
4
FOG
5 6
5
6
OTHER (SPECIFY)
1 2 3
NAME OF INVESTIGATING POLICE AGENCY:
INVESTIGATING AGENCY REPORT NO.
I do hereby claim damages from the State of Washington in the sum of $_____________. A separate claim form should be submitted for each claimant. The Claimant must sign this claim form unless he or she is incapacitated, a minor, or a nonresident of the state, in which case it may be signed on behalf of the Claimant by any relative, attorney, or agent representing the Claimant. I declare under penalty 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)