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Home My WebLink About12-29-2017 Rector, Suzanne-Rob-Z PROSECUTOR. :.OivUvZSSIONJ ERS DEPARTMENT.1 INSURANCE d1 12/29/2017 11:45:18 AM 201712290016 $0.00 Page:1 of 16 Claims Against Kittitas tYORuditorls/misc KCPROS IIIIII IIIIII III IIII 1111 IIIIIII IIIIII 111111111111111111111111111 KITTITAS COUNTY CLAIM FOR DAMAGES Return to: County Auditor 205 W 5th 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): SLk-L&-n]n e., RP .1y r- (An A 9,ob Rech)r 2. Phone (Home): 50q � -y( e (Work): (92-9 _ 4(04 0 3. Address (include former address 'f at present address for less than 6 months): 442— RvLLlkboa("%& L� Physical PD. B o x I S burrs v`)A q ?q Z. to Mailing 4. Date of Birth: 5. Date and Time of Incident: 91 3) 201 �- i� �� 30 am 6. Location of Incident: lei Fa r -cd rQ 9 1 of 3 Kittitas County Claim for Damages Form Revised 9/2012 Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 2 of 16 7 0 Describe in detail the defect which caused the injury: VO I'?- C c3"o "T) 'J'e -0— S -td aeci outs, &c Tom -Pav i 1\o n -For c1 horse. ShoalA -I-Mck arid, . i F . I A .. .. i chkIcl korse J 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. 2551 Get f�}� CI�f:Z,l rl - I ' 2 5 -`7y `i - U( _,PQ I J o e e SVA -en u -ex" - 501- q 2 5- &30 3 5 - 3�?-, a. 3'- 4'1Do 10. Was claim investigated by a police officer? Sheriff State Patrol City Police 11. Description of claimant's vehicle: Make Year Model: License No. 12. Describe what you did after the accident occurred: EK visk`-�- 13. Describe the conversations you had, if any, with County personnel during or after the incident occurred: No conn ci- 2 of 3 Kittitas County Claim for Damages Form Revised 9/2012 0 rl Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 3 of 16 14. Describe the damages or injuries which you ustain d as a result of the inc'dent: Pnr�n,l ie.r%r n� -re na( Ii n' u,< ,rtP_g � ern-)ck1tvmek 15. What is the amount of damages claimed? (Include estimates and bills, if available): As 0-F 1Olsl1-1 s-VvAtrrA01A xt03.:5 ��. 50 (Am I91.IAOC-L) a►��.go I E� vl si i Oloc 16. How did you identify the County as the party responsibly for your damage? 17. List the names and addresses of all witnesses to the incident: e.� stal in�5 18. Are you covered by insurance? 'I'L s If yes, who is your insurance agent/carrier? 5e-ir �P�V1r1 0C4�,p Dated this _Day of �J , 20. aa no L1.3q:oo) 6 Subscribed and sworn (affirmed) to before me this day ofLtt�i� 20 Seal \\ �\ •.......• �� , \� �;•�55�0N"Ai'•� Notary Public in and f r the State of W shmgton OSAR Y9N�'; cResiding at GC S i'X7u • pig\ -\G O = OU"a�r UJ ••.;UNE 05 ;�• �Ci\�` OF W NS'��\ 3 of 3 1 I I I1 ` Kittitas County Claim for Damages Form Revised 9/2012 Patient Financial Services ao lk� ()031912W lat 561:45:18 AM - Kittitas County, VV °,r ,� Ellensburg, WA 98926 YO -A'. Ho -me f re Firn'Gtk ADDRESS SERVICE REQUESTED KVH HOSPITAL PATIENT FINANCIAL SERVICES PO BOX 799 ELLENSBURG WA 98926 l�I�,�Il�l�l,IlO��°III,u��l�llt'll'��I�I��Illlnl Itllll�ll�'I INV0001 OUT 50 1 0 1 Pieties check here and show address or insurance a" rroceon on reverse site �— Please dotach top portion and rotum with paymonL IF PAYING BY CREDIT CARD FILL OUT BELOW, CARD NUMBER �`/�si.# ii 16'er :: AMOUNT SIGNATURE 1;1/15%;17 EXP. DATE CHECK CARD USING FOR PAYMENT El MASTERCARD® DISCOVER VISA KVH HOSPITAL PATIENT FINANCIAL SERVICES PO BOX 799 ELLENSBURG WA 98926 l�I�,�Il�l�l,IlO��°III,u��l�llt'll'��I�I��Illlnl Itllll�ll�'I INV0001 OUT 50 1 0 1 Pieties check here and show address or insurance a" rroceon on reverse site �— Please dotach top portion and rotum with paymonL a 0 SUZANNE H RECTOR PO BOX 366 ELLENSBURG WA 98926.1913 f,0105/i17 PHY!§ THERAPY SERVICES-` 2,1Q;3 75: �`/�si.# ii 16'er :: Service Date y�+ 1;1/15%;17 Current Balance 240.00 Statement Date 11/17/17 Agreement Amount Payment Due Date 5 12/07/17 ,FOR BILLING INQUIRIES CALL 509-962-9841 THANK YDU, FOR :GtIbDSING KVH. PleasePay Tfis�;4rnount� t�, 240 0U5 a 0 SUZANNE H RECTOR PO BOX 366 ELLENSBURG WA 98926.1913 f,0105/i17 PHY!§ THERAPY SERVICES-` 2,1Q;3 75: 1Z/15%17 ADJUSTMENT;:- KAISER,P,ERMANENTE. 247 58G1 1;1/15%;17 PAYMENT KAISER. PERMANfNTE 1,61;6 170;1 � GQu.NT 111 =R,, n � 5 Payments/Adjustments 1,863 75 ,FOR BILLING INQUIRIES CALL 509-962-9841 THANK YDU, FOR :GtIbDSING KVH. Q RETAIN THIS PirATION ' : ,PAYMENTS RECEIVED AFTER BILLING DATE WILL APPEAR ON NEXT STATEMENT i r R Lu II_ 1 4 UJ 0 —r Your insurance has processed this claim. This statement represents the balance due RECTOR, SUZANNE H VISII".`NU.MBER >. from you. Please remit your payment in full or contact our office to make 01643250 arrangements. If you have a question about how your insurance benefits or co-insurance amounts were determined,P4fl please contact your insurance directly. � GQu.NT 111 =R,, n Previous Balance 0 0 Payments/Adjustments 1,863 75 ,FOR BILLING INQUIRIES CALL 509-962-9841 THANK YDU, FOR :GtIbDSING KVH. �fZ"M`, t Current Balance tt r l no`'0`Oi K it RETAIN THIS PirATION ' : ,PAYMENTS RECEIVED AFTER BILLING DATE WILL APPEAR ON NEXT STATEMENT Filed 000485 01 01 51 000010040179.4 Filijtrkr�r�20t*WAjggWM - Kittitas County, WA Auditor - 20171229 16 Page F of 16 E � IIJJ rr �i��uuVV'' GGA °explanation of Benefits Kaiser Foundation Health Plan of Washington Member Services PLEASE SAVE THIS DOCUMENT FOR P.O. Bos 34590 Seattle, WA 98124-1590 YOUR RECORDS AND TAX PURPOSES. Important Plan Information Page No.: 1 of 1 Dear Subscriber: Print Date: 11/18/2017 19 SUZANNE H. RECTOR 442 BUCKBOARD LN ELLENSBURG WA 98926 Pati en t : - - - Member ID: Subscriber: Group: Group Number: Provider: Provider Acct. No.: Claim Number: Diagnosis Code: SUZANNE--H-.-RECTOR- - -- 01226189 SUZANNE H. RECTOR PEBB VALUE PLAN EAST 4090000 KITTITAS COUNTY FIRE PROTECTIC 198-2017-2880-1 1729928864000 M79606 Leg pain THIS IS NOT A BILL. This is an itemized slunmary of services that outlines provider charges, payments, and claims decisions based on your coverage contract. If you are responsible for any amount as noted in the Payment Slmmary, you may receive a separate statement. Thank you. 09/03/17 Ambulance transport A0427 SH $ 875.00 $ 875.00 $ 700.00 $ 175.00 3005 09/03/17 Ambulance mileage A0425 SH $ 9.50 $ 9.50 $ 7.60 $ 1.90 3005 TOTALS $ 884.50 $ 884.50 $ 707.60 $ 176.90 Notes: 3005 - SEE "AMBULANCE" IN THE BENEFITS DETAILS SECTION OF YOUR BENEFITS BOOKLET. In Network: Annual Deductible $ 250.00 $. 750.00 $ 0.00 $ 0.00 $ 250.00 $ 250.00 Out -of -Pocket Limit $ 3000.00 $ 6000.00 $ 176.90 $ 176.90 $ 1022.18 $ 1022.18 Out of Network: Annual Deductible $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 Out -of -Pocket Limit $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 Pharmacy: Out -of -Pocket Limit $ 0.00 $ 0.00 $ 0.00 Life Time Maximum: $ 0.00 $ 0.00 $ 0.00 Questions? Please call 206-630-4636, or 1-888-901-4636 (TTY/TDD: 1-800-833-6384), or you may submit your questions to the E-mail link at www.lcp.org/wa/membersel-vices. Please see back of page for appeals information. CLKGSY Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 7 of 16 If you have questions concerning your benefits and coverage decisions, please call toll-free 1-888-901-4636 (TTY WA Relay: 1-800-833-6388). Para obtener asistencia en espanol, Ilame al 1-888-901-4636. Appeals Process for Coverage Denials If you wish to appeal a decision, you must submit a request for appeal within 180 days of this notice, specifying why you disagree with the decision. Kaiser Foundation Health Plan of Washington ('Kaiser Permanente') will notify you of its determination or request written permission for an extension of time within 30 days of receipt of the request for appeal. You may submit your appeal request by mail, fax, or phone to Kaiser Permanente. A written request for appeal should include copies of your medical record, physicians' letters and any other printed material related to your request. Kaiser Permanente Member Appeals P.O. Box 34593 Seattle, WA 98124-1593 Toll -Free: 1-866-458-5479 Fax: 206-630-1859 If you are not satisfied with the initial decision on appeal or if Kaiser Permanente fails to grant or reject the request for review within the required timeframe, you may request another review of the decision. For more details on additional levels of review, please refer to your Certificate of Coverage or contact Member Appeals. If your health plan is governed by ERISA (most employment related health plans, other than those sponsored by governmental entities or churches - ask your employer about your plan) you have the right to file a lawsuit under section 502(a) of ERISA to recover benefits due to you under the plan at any point after completion of the initial appeals process. _--For questions about your appeal rights, this notice, or for assistance, you can contact: Kaiser Permanente Member Services Phone: 1-888-901-4636 CLKE3B - Commercial ��u S �N45e 8 AM - Kittitas Counj,%V) !��Or=/VC Ellensburg, WA 98926 Yozr Hetue for HerlMi ADDRESS SERVICE REQUESTED KVH HOSPITAL PATIENT FINANCIAL SERVICES PO BOX 799 ELLE14SBUAG WA 98926 I�I�e��l�l�l�ll��'Ilelirilillillr�ll'��I�1e01111rrll�llll�ll�" INV0001 EME 50 1 0 U4 ❑Please check here and Show address or Insurance correction on reverse Please detach by portion and return with payment. IF PAYING BY CREDIT CARD FILL OUT BELOW, CARD NUMBER 4�ilisifi Number Service Date AMOUNT SIGNATURE Current Balance 300.00 EXP. DATE CHECK CARD USING FOR PAYMENT s: MASTERCARD - ® DDIISCOVER lwzw� VISA KVH HOSPITAL PATIENT FINANCIAL SERVICES PO BOX 799 ELLE14SBUAG WA 98926 I�I�e��l�l�l�ll��'Ilelirilillillr�ll'��I�1e01111rrll�llll�ll�" INV0001 EME 50 1 0 U4 ❑Please check here and Show address or Insurance correction on reverse Please detach by portion and return with payment. 0 0 N SUZANNE H RECTOR PO BOX 366 ELLENSBURG WA 98926.1913 Your insurance has processed this claim. This statement represents the balance due from you. Please remit your payment in full or contact our office to make arrangements. If you have a question about how your insurance benefits or co-insurance amounts were determined, please contact your insurance directly. FOR. BILLING INQUIRIES CALL 509-962-9841 THANK YOU FOR CHOOSING KVH. RETAIN THIS PORTION PAYMENTS RECEIVED AFTER BILLING DATE WILL APPEAR ON NEXT STATEMENT RECTOR, SUZANNE H VISIT NUIVLB:ER /+ 01636675 Previous Balance .00 Payments/Adjustments . A 876.90 �t. 1 M-1 4 4�ilisifi Number Service Date - Y ,.• f +J. '617,150 Current Balance 300.00 Statement Date 09Z29/17 Agreement Amount Payment Due Date 10/19/17 please Pay This Amount 0 0 N SUZANNE H RECTOR PO BOX 366 ELLENSBURG WA 98926.1913 Your insurance has processed this claim. This statement represents the balance due from you. Please remit your payment in full or contact our office to make arrangements. If you have a question about how your insurance benefits or co-insurance amounts were determined, please contact your insurance directly. FOR. BILLING INQUIRIES CALL 509-962-9841 THANK YOU FOR CHOOSING KVH. RETAIN THIS PORTION PAYMENTS RECEIVED AFTER BILLING DATE WILL APPEAR ON NEXT STATEMENT RECTOR, SUZANNE H VISIT NUIVLB:ER /+ 01636675 Previous Balance .00 Payments/Adjustments . A 876.90 Filed or Record 12/29/201.7 1 I 5:98-faM � 2097 b.fl6 NAME TEL, NO. { } STREETADDRESS CITY/STATE ZIP fNS[9FiAP C 1NFORMATI( N INSURED'S NAME PATIENT RELATIONSHIP TO INSURED INSURED'S 0 SELF []SPOUSE CHILD 0 OTHER DATE OF BIRTH INSURED'S ID NO. SOCIAL SECURITY NO. GROUP ID NO. EMPLOYER NAME ADDRESS ZIP CITY/STATE TEL NO. ( ) INSURANCE CO. NAME ADDRESS ZIP CITY/STATE TEL,NO. ( ) 1A1CIVIt:N1 Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, Yakima Valley Radiology, P.C. PO Box 2925 Yakima WA 98907-2925 A Audio LWI ElIjof 2290016 PEl 16 CARD NUMBER. SECURITI CODE NAME ON CARD (PLEASE PRINT) ESP. DATE SIGNATURE AMOUNT STATEMENT DATE 10/20/2017 ACCOUNT # YVR246626 PAP THIS AMOUNT $50.00 Office Hours: 8:00am - 4:00pm Monday - Friday Pay online at www.ePayitOnline.com Phone: 509/248-6633 Toll Free: 800/510-5551 CodeID: YAKIMA11 Access #: 6602304-1-109 Patient: SUZANNE HEATH RECTOR I IIIIII VIII IIID VIII VIII ILII VIII VIII VIII VIII VIII II II IIT VIII VIII I I I I � I I I I � I II �� I � II It Ins.: KAISER GH NORTHWEST 1111111„I�I�IIII,II,II�IIIIIII�r11111111�I1nI,11�r11111111111 0551 SUZANNE HEATH RECTOR YVR246626 PO Box 366 Ellensburg WA 98926-1913 MAKE CHECK PAYABLE & REMIT TO: 1�111�1��11111111111111111111,1,111111111111111111111111111111��1 Yakima Valley Radiology, P.C. PO Box 2925 Yakima WA 98907-2925 0001 05351 AMOUNT PAI YAKIMAI1-0569480-0000000.6602304.001-000109-#005515.0001 j DETACH HERE AND RETURN THIS TOP PORTION WITH YOUR PAYMENT ❑ PLEASE CHECK BOX IF ABOVE ADDRESS IS INCORRECT AND INDICATE CHANGES ON BACK. USING THE RETURN ENVELOPE ENCLOSED DATE POST DATE CODE DESCRIPTION OF SERVICE CHARGE PAYMENT _ ADJ BALANCE - 09/12/17 93971 DUPLEX EXTREMITY VEINS UN 09/29/17 73718 MRI LOWER EXTREMITY NON J 10/19/17 KAISER GH NORTHWEST To pay this statement electronically go to inlnv.ePayitOnline,co7n 07- scan the barcode to the right with your mobile device or tablet $89.00 $89.00 $177.00 $50.00 $54.10 $72.90 SCAN FOR 0� MOBILE,} PAYMENT Total Balance: $139.00 Insurance Pending: $89.00 AMOUNT DUE NOW: $50.00 Patient: SUZANNE HEATH RECTOR Account Number: YVR246626 Statement Date: 10/20/2017 Location: KITTITAS VALLEY HEALTHCARE HOSP Yakima Valley Radiology, P.C. 315 Holton Avenue, Suite 102 Yakima WA 98902-3240 YAKIMA11-0569480-0000000-6602304-001-000109-#005515.0001 Phone: 509/248-6633 Toll Free: 800/510-5551 IRS# 91-0861108 1 PLEASE READ THE FRONT OF THIS FORM CAREFULLY BEFORE YOU COMPLETE ANY OF THIS INFORMATION! CORRI1�f�f�bRp�if��9 Ib:18 AM - Ki NAME i i ADDRESS CITY STATE ZIP SOC. SEC. NUMBER PHONE } EMPLOYER'S NAME EMPLOYMENT ADDRESS CITY PHONE } STATE ZIP TO THE INSURANCE COMPANY lease expedite payment as your insured will continue to receive monthly atements until the balance is paid. Please note the assignment of benefits. hank you. I X . .... ... ..... . I~.��. ... .... . AUTHORIZED. SIGNATURE: _ ..DATE . . utas County WA �I�T�1F7�9N��At�Sf�ll�iCLAIMs 1. If you wish our assistance to filing a claim for your health insurance benefits, please complete the form below and return it to our office. Failure to return the form automatically makes you responsible for payment In full. 2. If you noed another claim filed for a second insurance company, please make a photocopy of the front and back of this statement, then complete one form for each insurance carrier. Return all forms to our office. 3. Be sure to sign the appropriate authorization(s) below for each form submitted. PAT!ENT'S STATEMENT: Complete all items below and return to our office. Insurance Company Insurance Co. Telephone No Claim Office Address Policy Number Group Number Name of Insured _W____- --.Insured D.O.B. Insured Home Phone No. Relation of Patient to Insured Social Security Number Employer of Insured Employer's Address..____ Medicare No. Medicaid No. Employer's Telephone No. Was condition related to ❑ Employment ❑ Auto Accident Date of Accident/Injury Referring Physician -_ AUTHURI7.ATION: I HEREBY AUTHORIZE AND DIRECT MY INSURANCE CARRIER TO PAY DIRECTLY TO THE PROVIDER SHOWN ON THE REVERSE SIDE OF THIS FORM ANY BENEFITS DUE ME UNDER MY 114SURANCE PLAN, I AGREE- TO PAY THE BALANCE OF EXPENSES NOT PAIL) UNDER THIS PLAN, I FURTHER AUTHORIZE THE RELEASE TO MY INSURANCE COMPANY ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. BILLING &,INSURANCE_POLICY You alone, not your insurance company, are responsible for payment of your account, If, after receiving this statement, you are unable to pay in full, you must contact our billing office. if you have reason to believe this billing is incorrect and desire to dispute it, you must notify us in writing within 30 days of receiving this billing. If +roe do not hear from you, we will expect prompt payment of this bill. PLEASE NOTE: There may be a collection charge for checks that are not honored by your bank. Also, there may be an service charge added to past due accounts. We will bill Medicare for you, however, you must provide us with your Medicare number and signed authorization form provided to you at the time of service. If a form was not provided then please sign in the area marked authorized signature above. You will receive a regular monthly billing for any balance owing after payment by Medicare. IF YOU HAVE RECEIVED THE SERVICES OF A HOSPITAL OR OTHER MEMI:CAL FACILITY YOU MAY RECEIVE TWO SEPARATE BILLS. ONE FROM THE HOSPITAL OR MEDICAL FACILITY & ONE FROM. THE PHYSICIAN PROVIDING SERV.IC.ES. THE HOSPITAL OR OTHER MEDICAL FACILITY'S B[LL MAY BE SEPARATE FROM THE PHYSICIAN'S BELL. TOTAL COST ---- HOSPITAL OR MEDICAL FACILMCS FEE PHYSICIAN'S FEE The total cost for many medical services may be comprised of two fees. Each fee may be billed separately by the provider of the services. The hospital or other medical facility's fee covers the cost of providing the technicians, equipment and supplies involved. in performance ofd yo> r service. The physician's fee is for services provided by your physician or for services provided by a physician for the supervision., interpretation and consultation with your personal. physician. The physician .is an independent physician and may not be an employee of a, hospital or medical facility and therefore may bill separately for his or her professional service. DMS -1 GEN 0001 Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 12 of 16 n Name Name 11 GeiZA– 6�' �Ei'l� — A ddress: � Address: — City. State, Zip City, State, Zip Day Phone Number: Day Phone Number: Evening Phone Number: Evening Phone Number: Comments; iiLoav�-. s�r�i'tb �.+&e_ S7) 1 t/sC+0 1'.-qA-r, E -$c -o; "�5�G3�-. c b � '��..i� .�� '�' •'� ft -2 ?.A i 6E�. +QS L. t, sAs Sz�4-RTI t 17�v is tiz ta�� s�o�4. •`-.,� `�'t2�bf=��1 �c�.n,r�G�.�--� �,�,iZS• �-�GT'a� La e� Ei?.c�l�, c� A s"�`i P�- a� a � Dc ElrSt� I p�,Jz Z �- ii i� t �1✓S _ ►Z1,eTL9,e - WAS ttua_ �/D L� �Atc��f�- , +.�a�W bk_4t, A t.;�� AIr s. �..�.--� •� � '? ci.....rl �t� � L� �? � ' ci G%� C-�.vt.� r�e.� . -� t �4=c..�` � l.� � G 4 _te-PvLu An REFUSAL OF TREATMENT I have been advised to seek emergency medical treatment and transportation to a hospital or emergency l clinic. I hereby refuse to accept emergency treatment and/or transportation to a hospital or emergency clinic, and further hold harmless Kittitas County "and its personnel from damage and/or claims that may arise from my refusal of services. Signature: Witness: ......... Witness: Date: Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 13 of 16 Kittitas County Fair and Fairgrounds EVENT INCIDENPACCIDENT REPORTING FORM Fairgrounds representative INJURED: (Patron) (Employee) (Contractor) (Other: PC "'G� ) accident reported to or at scene: Name: Ji ;iZ ii n e-. F't"tc L' AGE: LIG HT: 47' WT: 150 SEX: L40 PHONE: ADDRESS: "PC tx) X CITY:C- AV nsbu(`CI STATF_�k)A ZIP: `` u — " SITE NAME/LOCATION: (Indoor) (Outdoor) TYPE: atr INJURY: / DATE: _9,1/1 -CSI -' INJURED BODY PART: L.( q CONDITION: Rwt ,A, -,j -i c (Sprain, Fracture, Concussion, 6tc.) OCCASION: '❑ ARRIVING AT SITE ❑ SETTING UP QUEUING ENTERING EVENTaIDE ❑DU.RING EVENTTUDE: (Early) (Mid) (.Late) ❑ EXITING EVEN URIDE ❑ BETWEEN EVENTS'RIDES ❑ DEPARTING SITE Name of Ride & Manufacturer or Special Event: AAC IVITY: ER NORMAL USE ❑HORSEPLAY ❑ FIGHTING WITH: ❑ OTHER: S.PF,CIAL CIRCUMSTANCES: NONE ❑ UNAUTHORIZED ACTIVITY ❑ EQUIPMENT -RELATED ❑ OPERATOR -RELATED ❑ INTOXICAITON: (Injured Person) (Other Person) ❑ OTHER: ival) (Parade) (livestock Show) (Other: ) TIME DISPOSITION Moming ❑ On -Site Care Only Afternoon Ambulance to; ❑ Evening t, 1K V ❑ After Hours ❑ .Refused Care ❑ Fatality LOCATION: ❑ PARKING LOT ❑ WALKWAY ❑AT RIDE: (Mechanical) (Dark) (Water) ❑ GAME BOOTH ❑ ANIMAL CAGE/STALL ❑ INDOOR ARENA ❑ OUTDOOR ARENA ❑ ARCADE , ❑ RESTAURANT ❑ IDWAY OTHER: Gt. VS,G(C blocy) SURFACE CONDITION: ❑ NOT APPLICABLE ❑ NORMAL OWBT ❑ ICY ❑ LOOSE GRAVEL ❑ IRREGULAR . ❑ OTHER: SITUATION: ❑ FALL (Slipped) (Pushed) (Tripped)' (Lost Balance) ,] HIT BY:.� ❑ COLLISION WITH: IF A FALL, SHOE WORNT: ❑ SNEAKERS ❑ SANDALS/THONGS ❑ SLIP-ONS ❑ LOAFERS ❑ WALKING SHOES ❑ PUMPS ❑ HIGH HEELS [j�BOOTS ❑ NONE ❑ OTHER: DESCRIBE HOW ACCIDENT HAPPENED: fjtoLjjdlo ^ Lill {„l "N P'41 Ctit K e+G Mon . WY\i��r �i'it" �'1"tri c' ��>x; tip �) 41 `:a�ctic C� " t)l'Je ,(,nuc vier- 1 w c,-tYuci~5 try', a L;,5 i.> 4� c: h (\ t cI^ o kkx rA - vi i_. 6,t t a 10 �: eC• A(Vty tawi^6c COt' �'1't�K�irk( i}tvi�iTt, tV1A :i arty_ . (Over for witness inforination) (print) r -C +u- 1.1 ") rt1�„ CYY.(' Citi aLpel-A brl Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 14 of 16 WITNESS INFORMATION Name: Name: Rob Rector Address: - Address: P.o. Box 366, 442 Buckboard Lane City. State, Zip City. State, Zip Ellensburg, WA 98926 Day Phone Number: I Dav Phone Number: 509-929-4645 Evening Phone Number: Evening Phone Number: 509-929-4645 i Comments: While Staging to enter the show arena outside of Bloom Pavilion with ponies, there were other horses exiting the arena. A pickup with a horse trailer and another pickup drove through which caused all of the horses and people to squish together closely. at the same time, there was a child walking a pig into the staging area that we were in. Dominics horse backed away from the pig while turning. This caused the horse to run into Suzanne with its hind end knocking Suzanne to the ground on top of Faith. The horse was trying to get away from the pig and the commotion, but was stomping on Suzanne's legs with its back legs while she was on the ground sheilding Faith. Suzanne got hit from behind and never saw it coming. I was standing next to Suzanne and saw it all happen, while nearly getting hit myself. I told Dominic to take the horse into the alley and yelled at the woman in the truck to get the truck away from us. She was stopped and was looking at. what was going on I guess. REFUSAL OF TREATMENT have been advised to seek emergency medical treatment and transportation to a hospital or emergency clinic. I hereby refuse to accept emergency treatment and/or transportation i to a hospital or emergency clinic,`and further. hold harmless Kittitas County i and its personnel from damage and/or claims that may arise from my refusal of services. i Signature: Date: Witness: Witness: i I P ., Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 15 of 16 Rob & Suzanne m: Jill Scheffer <jilt.scheffer@co.kittitas.wa.us> acnit: , Tuesday, October 24, 2017 2:58 PM To: Lisa Young Subject: FW; Witness report Attachments: img016.jpg Sorry! Thought it went with the reply O All Scheffer Director, Kittitas Valley Event Center Celli 509-899-7692 Office: 509-962-7675 Home of the Kittitas County Fair and the Ellensburg Rodeo August 30 — September 3, 2018 a Kittitas County. 1 901 East 71h Avenue Ellensburg WA 98926 iill.scheffer@co.kittitas.wa.us 1, http://www.co.kittitas.wa.us From: Sarah Maes Sent: Tuesday, October 24, 2017 2:25 PM Clay Myers; Jill Scheffer ,eject: FW: Witness report Have you both received this? Sarah 0,2off Program Assistant, Kittitas Valley Event Center Office: 509-962-7639 Home of the "Kittitas County Fair and the Ellensburg Rodeo August 30 — September 3, 2018 901 East 7th. Avenue Suite 11 Ellensburg WA 98926. sarah.maes@co.kittitas.wa.us http://www.co.kittites.wa.us From: farmerjklmCa)aol.com [mailto:farmerjklmCa�aol.com] Sent: Tuesday, October 24, 2017 12:00 PM To: Sarah Maes; harrelleburgCc�charter.net Subject: Witness report Q Nk%1 r: E.nl,a0 son' io KI,UiFis CrAin ty m—ay rx, sw; ;,,ct.`tt) I:,!lic disNrsurO cis 1-equirc d by !al . age il: at; 7 t59'i14 d00 Aa14 1 I I — Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 16 of 16 Name: Name: Address: Address: City, State, Zip City, State, Zip Day Phone Day Phone Number: Evening Phone Number: Evening. Phone Number: L\ Comments: -o I a Lf- 5-1 R L> ('V- 4 V Y, "W. L 'U) A V)orx , -) Y 17SO, e - N J '\V REFUSAL OF TREATMENT have been advised to seek emergency medical treatment and transportation to a hospital or emergency clinic. I hereby refuse to accept emergency treatment and/or transportation to a hospital or emergency clinic, and further hold harmless Kittitas County and its personnel from damage and/or claims that may arise from my refusal of services. Signature: Witness: Witness: Date: