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Filed for Record 11/01/2018 01:12:36 PM - Kittitas County, WA Auditor - 201811010016 Page 3 of 5 <br />14. Describe the damages or injuries which you sustained as a result of the incident: <br />Van door popped out of alignment and wouldn't close due to being hit by <br />the frame of the forklift. <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br />Enclosed is an estimate from L -P Body Shop for $1406.60 another came in at <br />$1700.00. We'll need a rental van while ours is in the shop but don't have pricing. <br />16. How did you identify the County as the party responsible for your damage? <br />County employee, Bryan Nass was driving the forklift when the <br />—damage occurred. <br />17. List the names and addresses of all witnesses to the incident: <br />Bryan Nass - 925 S Industrial Way, Ellensburg, WA 98926 <br />18. Are you covered by insurance? Yes ^If yes, who is your insurance agent/carrier? <br />Farmers' Insurance - Michael Hummel, Agent <br />ibed and sworn (affirmed) to before me this day of 203 <br />f; <br />Seal <br />Notary Public <br />State -of Washington <br />ELISABETH 6 MANSFIELD <br />My Appointment Expires Aug 17, 2020 <br />.r <br />Notary Public in an o he State of Washington <br />Residing at <br />3 of 3 <br />Kittitas County Claim for Damagcs Form <br />RcAsed 912012 <br />