HomeMy WebLinkAboutClaim for Damages•
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09/07/2018 09:38:09 AM 201809070003
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Claims Against County/ris/mist BAKER
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INSURANCE
KITTITAS COUNTY CLAIM FOR DAMAGES
Return to:
County Auditor
205 W 5'h Ave, Suite 105
Ellensburg, WA 98926
509-962-7504
Instructions: p
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. NNie (Including spquse, if married):
2. Phone (Home): d Z (Work): ( }
3. - Address (include former address if at present address for less than 6 months):
Mailing -
4. Date of Birth:.y,Lz1��
5. Date and T' e of Incident:
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on of Incident:
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Kitlitas County Claim for ]damages Form
Revised 92012
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7. Describe in detail the defect which caused the injury:
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Describe in narrative form and in detail exactly how the incident occurred:
List the names of all persons involved and contact information, if known.
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10. Was claim investigated by a police officer? 0
Sheriff State Patrol City Police
11. Description of claimant's vehicle:' Make O Year
Model: �% _ i� License No. Ukcd. /S 4101' e %
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12. Describe what you did after the accident occurred:
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13. 'Describe the conversati
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you had, if any, with County personnel during or after the
2 of 3
Kittitas County Claim for Damages Form
Revised 9/1012
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14. Describe the
injuries w14ch you sustained a4 a result of
15. What is theamount if damages claimed? (Include estimates and bills, if available):
15. How did ou 'den ' e Count%y as the party esponsible f r your c
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17. List the names and addresses of all witnesses to the incident:
18. Are you covered by insurance?f yes, who is your insurance agent/carrier?
Dated this —0—Day of"7�/ , 20_T.
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Subscribed and sworn (affirmed) to before me this �day of _,,, �. 20_�V
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No Public in and for the State of Washington
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/I 1 I''WAS\Ax Kittitas County Claim for Damages Farm
Revised 9/1012