HomeMy WebLinkAbout02-16-2016 Travis Kelly Claim for Damages (DOB Redacted)02/16/2016 10:12:22 AM 201602160002
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Claims Against Countylrlslmisc KITTITAS COUNTY PROS
Kittitas County fiuditor
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INSURANCE
KITTITAS COUNTY CLAIM FOR DAMAGES
Return. to:
County Auditor
205 W 5`h Ave, Suite .I05
Ellensburg, -WA 98916
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. Marne eluding spouse, if m ed :
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2. Phone (Home):01 } (Work): { }
3. Address (include former address if at present address for less than 6 months):
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Mailing
-4. Date of Birth:
5. Date and Time ofIncident:
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6. Lo tion of Incident:
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Kittitm County Claim for Damages Form
Revised 912012
Filed for Record 02/16/2016 10:12:22 AM - Kittitas County, WA Auditor - 201602160002 Page 2 of 4
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Describe in detail the defect which caused the injury:
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Th detail exactly how the incident occurred:
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:--x-)AMake Year
Model: License No.
12. Describe what you did after the accident occurred:/
13. Describe the conversations you had, if any, with County personnel during or after the
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Kittitas County Claim for Damages Form
Revised 912012
- ' Filed for Record 02/16/2016 10:12:22 AM - Kittitas County, WA Auditor - 201602160002 Page 3 of 4
14. Describe Jhe damages or injuries which you sustained as,a result o�the
15. What is the amount of damages claimed? (Include estimates and bilis, if available):
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16. H1 w dy you iderl ify the County as the party esp❑ sible fa your damage?
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17. List the names and addresses of all witnesses to the incident:
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Are you covered by insurance?zLrIf yes, who is your insurance agent/carrier?
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Kittitas County Claim for Damages Form
Revised 912012
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