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HomeMy WebLinkAbout03-06-17 Gilge, Rodney03/06/2017 11:19:05 AM 201703060010 $0.0© Pa9e:i of 8 KittmtaCAgnty sGRudito�is/mise KGPROS 1111111114111111111111!11111111111111111 II1111411111111111 IS 1111111111111 I'ROSidPA CON IISSIONERS DEPARTMENT INSURANCE - KITTITAS COUNTY CLAIM FOR DAMAGES Return to: County Auditor 205 W 5h Ave, Suite 105 Ellensburg, WA 98926 509-962-7504 Instructions: Please read the entire form before completion. Fill out each question as completely as possible, to the best of your ability. Do not hesitate to use the back side of this form if you need more than the space provided. An incomplete response may delay the processing of your claim. Name (Including spouse, if married): 'RoAfeq ( I' kRe- S;)Nwovn Ci�5r0 2. Phone (Home): ( 56t - � (Work): ( 3 0 ) 3. Address (include former address if at present address for less than 6 months): 4603 SOU+\\ Cccen Pig i iiCeni\L-cjic;K u-)fi `tj33`7 Physical Gcc%e a3 (z60u1; Mailing ` 4. Date of Birth: 5. Date and Time of Incident: 6. Location of Incident: —(-%o F-Kk+ tai a Ca��a�► C� o�eQ 1 of 3 Kittitas County Claim for Damages Form Revised W2012 Filed for Record 03/06/2017 11:19:05 AM - Kittitas County, WA Auditor - 201703060010 Page 2 of 8 7. Describe in detail the defect which caused the injury: e �g& iwa,K� % 3 (t i -u r�� Kc`tfi � 6t -a CC-)UAty L1, 'pe \ flhc�rceci kik 0 tip e 1`QY� ' At the }� Q eK o� ✓h `t� ea. Describe in narrative form and in detail exactly how the incident occurred: 9. List the names of all persons involved and contact information, if known. Rcoj rke; c',a%_ 5%5-01iV l Ar�te�. ���me 5�� —g62— X4525 !&hevkffs 'Pg$v04 Sargent 501- T62 ..'52'S 10. Was claim investigated by a police officer? E$ Sheriff State Patrol X City Police 11. Description of claimant's vehicle: i'A ereehos '6eav--. Make 2 0 V9 Year Model: M\ -I-) ISO License No. PkU ? gOoO 12. Describe what you did after the accident occurred: with PANdcec,. gku°ae VA 40CAot- 4, C- vQ(65 Vemelt IN�ter e,trh� i �� it��&Vft ikon and qe �(1q aA `� txeh��ge dF l\\�LXVM't'ao'�� F� n\ 3PCom OkEceQ FeCCekt�t�� ueel on s +Uau 13. Describe the conversations you had, if any, with County personnel during or after the incident occurred: `ik\C- cowni-t o-ecsonaei O.c we-�A 'Lt mas, their Vixok-f (t +AA tie (,t%c+ -tiv h ) A. Rksir, Pw 4 , 2 of 3 Kittitas County Claim for Damages Form Revised 9!2012 Filed for Record 03/06/2017 11:19:05 AM - Kittitas County, WA Auditor - 201703060010 Page 3 of 8 14. Describe the damages or injuries which you sustained as a result of the incident: (1\,x 60'%AyeC Qi'A Gi Gic�je� SJ CQ�}S (fil7S Alli�C �%3e� c ruA end , 15. What is the amount of damages claimed? (Include estimates and bills, if available): NJ 16. How did you identify the County as the parry responsible for your damage? �� a� r�i `sc�ss ��ng c���1� -tie co��.�� �et-s�a�► ed �,� Ae scene r to w�A-h AV%Cer �errel0 17. List the names and addresses of all witnesses to the incident: hetc w ete tooy, A td Pss,-s e-Ac@4 "khe.y yr1X' es 18. Are you covered by insurance?�If yes, who is your insurance agent/carrier? SA'Ae_ eY adviS-e'f me ftni f© (0 Q cls` �► g ll t\-4 SkaAe VoCM -c"O \ce wevld kuc- to 5)Q tl�e- # Dated this 3 s A Day of 20 1� . Signature of Claimant ` \ d sworn (affirmed) to before me this day of NI(l`( '20 40 OTA 'lee �°,S'al51 �_ ' NA %, ,oGB��� s 2 otary Public in and for the State of Washington '9j ,'�a,�o,pgA®; Residing atQ.Y1�oY1 3 of 3 Kittitas County Claim for Damages Form Revised 9/2012 _ Filed for Record 03/0 1 'tas County, WA Auditor - 201703060010 Page 4 of 8 STATEOFWASIiINWON �� I� l�l POUCE TRAFFIC I I ( �II REPORT NO. E646597 2 3 COLLISION REPORT 1591971 F-7-7 RE CASE # ? m INTERSTATE 91CITY STREET ❑ F�SULTED ❑ STOLEN 1� STATERDUrB ❑ OTHER ❑ VEHICLE ❑ LOCAL AGENC 3 NIm T& RUN CODING COUNTY RD ❑ PRNATE WAY ❑ INVOLVED ❑ Q 2� TRIBAL TOTAL * OF 2 OEUECT 1 S 26 RESERVATION UNITS STRUCK m 35-1 M M D D Y Y V Y TIME (2400) COUNTY MILES IN CITY R 2 SISI 2 - 28 19 - 2017 1200 � S ❑❑ w ❑ OF ❑ 0380 3 m 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON-INTERSECTION I-90 EXIT 109 MILE POST 0 109 O-0 3LOCK MO. 0 6 29 48 ❑ DISTANCE OF (FIEFERENCE OR CROSS STREET) s 20 00 MILES O S W ✓CANYON ROAD ❑ S°E o`-"�PHONE YE�f-j (509) 962-7069UNT 01Q 0 6 30 6a -sTNAME I BLUME FIRSTNAME I ANDREA j L 307 WEST UMPTANUM 7❑ FTELLENSBURG ST WA 98926 1 2 at 61-1 CDL RESTRICTIONS ENDOTISSEAIENTS Z m sF ucE1NSEs BLUMEAL237C3 STATE WA SEX F 1,,,D,,O,,N 2 - 23 1977 3m 16F2] ON DUTY ✓❑ STATUS AIRBAG 2 RESTR. 4 EJECT 1 HELMET INJURY 1 NATUREOFINJURES 1 2 1 2 uCENSE2 m 11❑ AFK8903 WA ma 1FM5K8ARXDGC26146 PLATE* m 3 TRAILER STATE TRAILER 12 PLATE AI PLATE g STATE VEH. YEAR A E STYLE VEH1 T D TOMO BY G mcu to 2013 FV6RD PLORER UT YES No ✓ No ✓ 13© REGLSTEAIDOWNERINFO. VEHICLE NO. I 3 7 KITTITASCO PHONE#. (509)962-7069 SHADENDAMAGEDAREA Hw ,o 14© su I ✓❑ aP ' eEOO WA: CO RISK POOL KITTITAS COUNTY 3 • 3 734 CITAitON D CHARGE �u - 5 5,5, OO�NG � ❑� 15a e a UNiT 02 vOEITnaORE aF ❑ �DRIA" ❑ a ❑ l Ho LD"'ET P"°NE (509) 585-074735 16� ® 36 LAsrNAa,+eE GILGE FIRST NAME RODNEY N AL L 1711 STREET4603 S GREEN PL EIJv NEIYAODRESS m 16F] crrY I KENNEWICK I sr I WA 17IP 993372617 EE39 19F] CDL RESTRICTIONS ENDORSEMENTS m46 26� DwE GILGERL530KA STATE WA SEX M „D,,,op B' S -M- 1947 mF j ON DUTY ❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H V C 1 1 rT of uuuRlEs 22 F1 LICENSE I P ATE# AVP9000 WA N* 4JGDA5HB1FA595845 23m I TRAILER I STATE PL ATEA STATEPLATE 41 24❑ VEH. YFAR MAKE MODEL STYLE VEHI TOVVE TOWED BY 2015 MRBN ML350 UT YES NO ,/ ND ✓ 1 42 RCGLSTEREDOWNERINFO. VEHICLE NO- 2 OWNED BY DRIVER SWENwMAGEDAREA INEFRCTS &FLANM Z 11 E"O STATE FARM 310 0812-C22-471 z 3 4 ZSm Mn"Fy. m ❑ No CTATION D CHARGE I iu BOTTOM s B 7 a OFfIC6T5 UAME (PRINT) TiADGE OR TO a AGENCY 26M FERRELL, CHARLES 847 WASHINGTON STATE PATROL PAGE 01 OF 4 PART A ��.5-,� A �,�, Filed for Record 03/06/ - as County, WA Auditor - 201703060010 Page 5 of 8 STATE OF WASH ` POLICE COLLISION RGTOH EPORT REPORT NO. E646597 1591972 CASE # ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WrTNESSES ONLY) NAME aAnRBST. =DLE IN(TIAQ ADD RESS& PHONE SIX D.O.A MMM"YY - - R s ENGER❑ WITNESS❑ UNIT# � P� AIRBAG AIRBAG RESTR. EJECT H3ET INJURY NAnJW OF lMURIES HATUREOFruuREs DIAGRAM Please see subsequent diagram page INDICATE NORTH BYARROW 0 NARRATIVE Please see subsequent narrative e s E ASS NAME MST. RRSL MCME INR AQ Al O -B &PHONE 0 SEX D.O.B. -1— D MMODVYYY —F PASSENGER WRNESS❑ UNRY POS AIRBAG RESTR. EJECT HELMET IUSE NATURE OF WURES CLASS NAME QA9T, RRS%MM-E INMW AOOFo�&PHONE S SEX— MMDDYYYY PA85HVGER ❑ WTiNESS❑ UNIT Y � AIRBAG RESTTT. EJECT HELMET ICL AW NAnJW OF lMURIES DIAGRAM Please see subsequent diagram page INDICATE NORTH BYARROW 0 NARRATIVE Please see subsequent narrative e s I CERTIFY (DECLARE) UNDER PENALTY OF PERJURY UNDER 714E LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. (RC W 9A.7208S) CHARLES FERRELL 2/28/2017 INVESTIGATING OFFICER'S SIGNATURE UNITOR DIST. OET DATED PLACE SIGNED `PWOVWBY Mulvaney, Brian 108 01� BADGE OR ID If 847 ORIR I WAWSP0000 TIMEPouCEDISPATmED 12:18 PM-nMEPOUCEARRIVED 12:23 PM PART B a000-345•160 R aural PAGE FT] OF Filed for Record 03/06/2017 11:19:05 AM - Kittitas County, WA Auditor - 201703060010 Wdo8ftfAumber: E646597 Narrative Vehicle 2 was in front of vehicle 1 as they were stopped at the bottom of the offramp at 1-90 west exit 109. The light was red and initially both vehicles were stopped at the intersection and waiting to tum right onto northbound Canyon Road into Ellensburg. Vehicle 2 started to move forward and make the right tum_ Vehicle 1 then started to move forward towards the intersection behind vehicle 2. The drivers from both vehicles were looking to the left towards oncoming traffic. There was a vehicle traveling northbound on Canyon Road in the left lane (Canyon Road has two lanes designated for northbound traffic). Seeing this other vehicle traveling northbound on Canyon Road, driver 2 stopped his vehicle prior to making the right tum_ The front of vehicle 1 hit the rear of vehicle 2. Both vehicles pulled into a gas station parking lot just north of this intersection. PAGE 3 of 4 Filed for Record 03/06/2017 11:19:05 AM - Kittitas County, WA Auditor - 201703060010 Page 7 of 8 Report Number: E646597 Shoukler To 1-90 West From I-C.0Wem Left Tum Right Tran Shoulder 0 • a� C7 IfIed Traff: Lght PAGE 4 of 4 Filed for Record 03/06/2017 11:19:05 AM - Kittitas County, WA Auditor - 201703060010 Page 8 of 8 McCurle Integrity Joe Brackensick Estimate Y Y McCurley Integrity Dealerships Dealerships PO Box 2698 Tri -Cities, WA 99302 Fax Number: 509-736-1619 Business Phone: 509-736-1682 Joe. bracke nsick@mccu rley. net Owner: SHARON GILGE, WA Veh. Info: 2015 Mercedes-Benz ML350 4 Door Utility AWD 3.5L 6 Cyl Gas Injected , VIN#: 4JGDA5HB1 FA595845 Descciptton� ' ,: e�� �: =Part # , * x.v E.'Price Labor . REAR LAMPS' R&I R REAR COMBINATION LAMP OEM Parts 0.4 hrs. Body R&I L REAR COMBINATION LAMP Body Labor 4.0 0.4 hrs. Body 'REAR.SUMPER.. Paint Labor 3.0 $70.00 Replace REAR BUMPER COVER 166 885 03 25 9999 $1,330.00 1 Included, 3.Ohrs. Paint panel , 1.2hrs. $84.00 • Body Supplies 4.0 Clearcoat Overhaul REAR BUMPER COVER ASSY Paint Supplies 3.0 3.2 hrs. Body Replace REAR CTR BUMPER PLATE 166 885 21 74 $119.00 1 Included Replace REAR UPR BUMPER MOULDING 166 885 22 74 $197.00 1 Included Replace REAR LWR BUMPER MOULDING 1668852374 $179.00 1 Included Replace REAR BUMPER VALANCE PANEL 166 885 19 25 $370.00 1 Included Totals Powered By Rffimsu Page 1 of 1 3/3/20171:39:33 PM OEM Parts $2,195.00 Body Labor 4.0 $70.00 $280.00 Paint Labor 3.0 $70.00 $210.00 Clearcoat Labor 1.2 $70.00 $84.00 Body Supplies 4.0 $20.00 $80.00 Paint Supplies 3.0 $45.00 $135.00 Taxable Amount $2,984.00 Tax 8.600% $256.62 Grand Total $3,240.62 Net Total $3,240.62 Powered By Rffimsu Page 1 of 1 3/3/20171:39:33 PM