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$100,000.00 KT2021065373 <br />AMOUNT OF POLICY AT SWORN STATEMENT POLICY/CLAIM NUMBER <br />TIME OF LOSS IN <br />PARTIAL PROOF OF LOSS <br />10/1/2020 TO THE Tacoma, WA <br />ISSUED AGENCY AT <br />10/1/2021 Arthur J. Gallagher <br />EXPIRES AGENT <br />Washington Counties Risk Pool <br />of Tumwater, WA <br />At time of loss, by the above indicated policy of insurance our insured <br />Kittitas County <br />against loss by All Risk to the property described under the above policy, according to the terms and <br />conditions of the said policy and all forms, endorsements, transfers and assignments attached thereto, <br />TIME AND A Water Damage loss occurred on the 11 February, 2021 <br />ORIGIN The cause and origin of the said loss were: fire supression system in the grandstands ruptured <br />causing ensuing water damage <br />OCCUPANCY The building described, or containing the property described, was occupied at the time of loss as follows, <br />and for no other purpose whatever: NONE <br />TITLE AND At the time of the loss the interest of your insured in the property described therein was: OWNER <br />INTEREST No other person had any interest therein or encumbrance thereon, except: None <br />CHANGES Since the said policy was issued there has been no assignment thereof, or change of interest, use, occupancy, <br />possession, location or exposure of the property described, except: None Known <br />TOTAL THE TOTAL AMOUNT OF INSURANCE upon the property described by this policy was, at the time of <br />INSURANCE the loss, $100,000.00 as more particularly specified in the apportionment attached under <br />the policy besides which there was no policy or other contract of insurance, written or oral, valid or invalid. <br />VALUE THE ACTUAL CASH VALUE OF said property at the time of loss was <br />LOSS THE WHOLE LOSS AND DAMAGE was 5 33,822.02 <br />DEDUCTIBLE Less the APPLICABLE DEDUCTIBLE $5,000.00 <br />DEPRECIATION: Less WITHHELD RECOVERABLE DEPRECIATION <br />AMOUNT THE AMOUNT CLAIMED under the above numbered policy is <br />CLAIMED <br />528,822.02 <br />The said loss did not originate by any act, design or procurement on the part of your insured, or this affiant; nothing has been done or with the <br />privity or consent of your insured or this affiant, to violate the conditions of the policy, or render it void; no articles are mentioned herein or in <br />destroyed or damaged at the time of said loss; no property saved has in any manner been concealed, and no attempt to deceive the said company, <br />as to the extent of said loss, has in any manner been made. Any other information that may be required will be furnished and considered a part of <br />this proof. <br />Pursuant to x.48.135.080, Washington Statutes, "It is a crime to knowingly provide false, incomplete, or misleading information to an <br />insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits." <br />The furnishing of this blank or the preparation of proofs by a representative of the above insurance company is not a waiver of any of its rights. <br />i1 t 1-b[T IN C { (-4.6 V- V Insured <br />�� y► sland <br />r <br />i(P W7." a <br />� ' AZ/e, '9�rrtl fl�1a�27�-�4' <br />r'`IO, wp o,. <br />11111 <br />to before me this I + day of _AJfrl 1 20 --7-1 <br />�_ __ Notary Public <br />