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14. Describe the damages or injuries which you sustained as a result of the incident: <br />DAMAGE TO POWER POLE #46-04-020, HAD TO BE REPLACED <br />15. What is the amount of damages claimed'? (Include estimates and bills, if available): <br />56.211.75 <br />16. How did you identify the County as the party responsible for your damage? <br />COUNTY CREW CONTACTED PUD <br />17, List the names and addresses of all witnesses to the incident: <br />HANS SPOELSTRA, RYAN BERGE KELEY DORMAIER ? <br />I& Are you covered by insurance'? YES 11 -yes, who is your insurance agent. earner? <br />FEDERATEDINSURANCE <br />Dated this 5TH Day of MARCH .20 18 <br />MATT BOAST, GENERAL MANAGER <br />Signature of Claimant <br />Subscribed and sworn (affirmed) to before me this 5TH day of MARCH ?p 18, <br />seal .v wiutrti <br />Ful-SO�h,� Notary Public in and for the State of Washington <br />C.,,,,,,.,n �i <br />�. ,afxrrgf�,, i Residing at <br />oJz Jeu 2 = <br />tig_,; 5� W 3 of 3 <br />�j �qo���...•o` ti = Krttuas Couro Cla&n Gx Da:am_n: (omi <br />ST q1 - <br />rrrttt tq <br />TE Of �.` ams<a �.mz <br />