HomeMy WebLinkAbout01-25-2016 Claim for Damages - Backstrom, Michael et ux (Redacted)03/25/2016 04:59:08 FM 201601250075
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Claims Rgainst Countylrlstmise PROSE UTOR
KittitasCounty Auditor
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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.
I. Name (Including spouse, if married):
2_ Phone (Horne):( 501 IA5 I I �) (work): {V W M)
3. Address (include former address if at present address for less than 6 months):
£ny., r� k mill M . �wsLu
- Mailing -
4. Date of Birth: jmm--�
5. Date and Time of Incident: r 1
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1 of 3
Kittitas County Claim for Damps Form
Revised 912612
Filed for Record 01125/2016 04:59:08 PM - Kittitas County, WA Auditor - 201601250079 Page 2 of 4
7. Describe in detail the defect which caused the injury:
S. Describe in narrative form and in detail exactly how the incident occurred:
Se a
-47
9. List the names of all persons involved and contact information, if known.
10. Was claim investigated by a police officer?
Sheriff State Patrol City Police
11. Description of claimant's vehicle: & Make
Model: License No.�
-- 12.
Year
y
13. Describe the conversations you had, if any, with County personnel during or after the
incident occurred:
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2 of 3
Kittitas County Claim for Damages Form
Revised 912012
Filed for Record 01 /25/2016 04:59:08 PM - Kittitas County, WA Auditor - 201601250079 Page 3 of 4
14. Describe the damages or injuries which you sustained as a result of the incident:
15. What is the amount of damages claimed? (Include estimates and bills, if available):
- 5
16. How did you identify the County as the party responsible for your damage?
17. List the names and addresses of all witnesses to the incident:
18. Are you covered by insurance? If yes, who is your insurance agenticarrier?
Dated this A --U Day of 20U.
Subscribed and sworn (affirmed) to before me this day of
Seal
-votaryYumic in anu xor the Zitate or Wasnington
Residing at
3 of 3
Kittitas County Claim for Damages Form
Revised 9/2012
Filed for Record 01!2512016 04:59:08 PM - KittitasCounty, WA Auditor - 201601250079 Page 4 of 4
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