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January 26, 2016
Mr. Michael P. Nigrey
Deputy Prosecuting Attorney
205 West Fifth, Room 213
Ellensburg, WA 98926-3129
KZTTZTAtS COT,TNTY
DEPARTMENT OF PUBLIC WORKS
Mark R. Cook, PE Director
RE: Claim No.: 201601250079
Dear Mr. Nigrey:
Public Works has reviewed the claim for damage (Exhibit 1) submitted by Michael and Jennifer
Backstrom (01-20-2016 No. 201601250079). We confirm that Public Works was engaged in
snow plowing operations on 01-20-2016 along Brick Mill Road. The damages listed are
consistent with our experience resulting from either snow striking or inadvertent contact with a
mailbox. The requested amount for replacing the damaged mailbox is consistent with our cost
history. We find no reason to dispute the narrative of the claim as submitted. We recommend
that the Board of County Commissioners favorably entertain the Backstrom's claim for damages.
Respectfully,
Mark R. Cook
Director/Interim County Engineer
Attachments: Exhibit 1 Claim No. 201601250079
C: Lisa Young, Risk Manager
411 N. Ruby St, Suite #1 TEL (509) 962-7523
Ellensburg, WA 98926 FAX (509)962-7663
01/25/2016 04:59:08 PM 201601250079
$0.00 Page:i of 4
Claims Against County/rlslmiso PROSECUTOR
Kittilas County Auditor
1111111111111111111111111111111111111111111111111111
PROSEI<'U7R (S
COMMISSIONERS,„
DEPARTMENT Z
INSURANCE
KTfTITAS COUNTY CLAIM FOR DAMAGES
Return to:
County Auditor
-205 W 5t' 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
1. Name (Including spouse, if married):
2. Phone (Home):( 50'163 I� 17 )(work): (" I W-ZW)
3. Address (include former address if at present address for less than 6 months):
4.
5.
6.
Physical 9N J_,1 ;—L Mil' LA .'F/I1Y/VlS64
sung J_.
Date of Birth:
1 of 3
Kittitas County Claim for Damages Form
Revised 92012
Filed for Record 01/25/2016 04:59:05 PM - Kittitas County, WA Auditor - 201601250079 Page 2 of 4
7. Describe in detail the defect which caused the injury:
a
J
10.
11.
12.
Describe in narrative form and in detail exactly how the incident occurred:
List the names of all persons involved and contact information, if known.
Was claim investigated by a police officer? O
Sheriff State Patrol City Police
Description of claim�1 A! ant'slveehicle: Make Q
Model: N License No. FI
Describe what you did after the accident-ocQ-=d:
13. Describe the conversations you had, if any, with County personnel during or after the
incident occurred:
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2of3
Kittitas County Claim for Damages Form
Revised 912017
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):
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:
1� /A
18. Are you covered by insurance? If yes, who is your insurance agent/carrier?
Dated this Day of 20u.
Subscribed and sworn (affirmed) to before me this day of 20_
Seal
Notary Public in and for the State of Washington
Residing at
3 of 3
Kittitas County Claim for Damages Form
Revised 92012
Filed for Record 01125/2016 04:59:08 PM - Kiftitas,-County, WA Auditor - 201601250079 Page 4of4
THANK YOU FOR SHOPPING AT
WOODS ACE HARDWARE
(509) 925-2981
01/20/16 3:10Pj TRICIA 552 SALE
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TOTAL: 21.59
BC ANT: 21.59
BK CARD#: XXXXXXXXXXXX6588
ID: 191200552880
AUTH: 361244 AMT: 21.59
Host reference #:201218 Bat#
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Acct: CASH CUSTOMER
KEEP YOUR RECEIPT FOR RETURNS
NO RETURNS AFTER 60 DAYS
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