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Home My WebLink About11-01-2018 Interstate Batteries of Apple Valley.........o....,.-_ - - - --- MMM �qp �' 11/01/2018 01:12:35 PM 201811010016 $0.00 Page:1 of 5 Claims Against County/rlslmisc KC PROS Kittitas County Auditor .4., ! ll 111111! ll [ll ![1111111 II II l Illll I 11 111111 INIII KITTITAS COUNTY CLAIM FOR DAMAGES Return to: County Auditor 205 W 5"' 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): Cesar Va uera - employee of Interstate Batteries of Apple Valle Bryan Calamia - Vice President of Interstate Batteries of Apple Valley cell 2. Phone (Ig): ( 509-731-7537 )_ (Work): 509-457-3640 3. Address (include former address if at present address for less than 6 months): 2001 Ahtanum Rd Yakima, WA 98903 Physical (Business addresses) PO Box 8311 Yakima WA 98908 Mailing 4. Date of Birth: 1/3/79 Cesar 5. Date and Time of Incident: 10/25/18, 3:00 PM to 4:00 PM 6. Location of Incident: 925 S lndustri I Way Ellensbure. WA 98926 1 of 3 Kittitas County Claim for Damages Form Revised 912012 Filed for Record 11/01/2018 01:12:36 PM - Kittitas County, WA Auditor - 201811010016 Page 2 of 5 7. Describe in detail the defect which caused the injury: No iniury, must van damage on inside due to being popped out about 1/2" with forklift. Frame upper left side door wouldn't closed a misalig Describe in narrative form and in detail exactly how the incident occurred: Bryan Nass used forklift to place pallet inside van. Upon placing it inside he backed up to pull out and hit van door which popped it out and door wouldn't close. It was hit with forklift on the frame on left side. 9. List the names of all persons involved and contact information, if known. —Bryan -Nass and Cesar Vaquera 1.0. Was claim investigated by a police officer? No Sheriff State Patrol City Police 11. Description of claimant's vehicle: Ford Make 2017 Year Model: Transit T250 License No. C44626M 12. Describe what you did after the accident occurred: Bryan Nass and I tried to fix the alignment of the van door so it would close. 13. Describe the conversations you had, if any, with County personnel during or after the incident occurred: I contacted mV boss Br an Calamia to see what to do. Bryan Nass and 1 put wire rope from the door to handle to secure it and keep it from opening. 2 of 3 Kittitas County Claim for Damages Form Revised 912012 Filed for Record 11/01/2018 01:12:36 PM - Kittitas County, WA Auditor - 201811010016 Page 3 of 5 14. Describe the damages or injuries which you sustained as a result of the incident: Van door popped out of alignment and wouldn't close due to being hit by the frame of the forklift. 15. What is the amount of damages claimed? (Include estimates and bills, if available): Enclosed is an estimate from L -P Body Shop for $1406.60 another came in at $1700.00. We'll need a rental van while ours is in the shop but don't have pricing. 16. How did you identify the County as the party responsible for your damage? County employee, Bryan Nass was driving the forklift when the —damage occurred. 17. List the names and addresses of all witnesses to the incident: Bryan Nass - 925 S Industrial Way, Ellensburg, WA 98926 18. Are you covered by insurance? Yes ^If yes, who is your insurance agent/carrier? Farmers' Insurance - Michael Hummel, Agent ibed and sworn (affirmed) to before me this day of 203 f; Seal Notary Public State -of Washington ELISABETH 6 MANSFIELD My Appointment Expires Aug 17, 2020 .r Notary Public in an o he State of Washington Residing at 3 of 3 Kittitas County Claim for Damagcs Form RcAsed 912012 i Filed for Record 11/01/2018 01:12:36 PM - Kittitas County, WA Auditor - 201811010016 Page 4 of 5 Customer: INTERSTATE BATTERY Insured: INTERSTATE BATTERY Type of Loss: Point of Impact: Owner: INTERSTATE BATTERY 2001 AHTANUM RD YAKIMA, WA 98903 (509) 457-3640 Business L -P BODY SHOP Workfile ID: Federal ID: 410 E ARLINGTON ST, YAKIMA, WA 98901 Phone: (509) 453-5671 Preliminary Estimate Written By: DAVID PICKETT Policy #: Claim #: Date of Loss: Days to Repair: 0 Inspection Location: Insurance Company: L -P BODY SHOP 410 E ARLINGTON ST YAKIMA, WA 98901 Repair Facility (509) 453-5671 Business VEHICLE 2017 FORD Transit Van T-250 Medium Roof 130" WB 9000# GVWR w/Sliding Right Hand Door 3D VAN 6-3.7L Flex Fuel Sequential MPI 7f821569 911188589 VIN: 1FTYR1CM7HKA75338 Interior Color: Mileage In: Vehicle Out: License: Exterior Color: Mileage Out: State: Production Date. Condition: Job #: TRANSMISSION Console/Storage Stereo SEATS Automatic Transmission Overhead Console Search/Seek BuckIt Seats Overdrive CONVENIENCE Auxiliary Audio Connection Reclining/Lounge Seats POWER Air Conditioning SAFETY WHEIELS Power Steering Intermittent Wipers Drivers Side Air Bag Styled Steel Wheels Power Brakes Tilt Wheel Passenger Air Bag PAINT Power Windows Keyless Entry Anti -Lock Brakes (4) ClearCoat Paint Power Locks Telescopic Wheel 4 Wheel Disc Brakes OTHER Power Mirrors Backup Camera w/Parking Sensors Traction Control California Emissions DECOR RADIO Stability Control Dual Mirrors AM Radio Front Side Impact Air Bags Tinted Glass FM Radio Head/Curtain Air Bags 10/26/2018 2:51:57 PM 084137 Page 1 MyPriceLink Estimate ID / Quote ID: 485204504342487040/38190648 THIS IS AN ESTIMATE BASED OFF A VISUAL INSPECTION. IT DOES NOT TAKE INTO CONSIDERATION HIDDEN DAMAGES THAT MAY ONLY BECOME EVIDENT ONCE THE REPAIR PROCESS HAS STARTED. THANK,YOU FOR UNDERSTANDING. IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO SAN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS. 10/26/2018 2:51:57 PM 084137 Page 2 Filed for Record 11/01/2018 01:12:36 PM - Kittitas County, WA Auditor - 201811010016 Page 5 of 5 Preliminary Estimate Customer: INTERSTATE BATTERY 2017 FORD Transit Van T-250 Medium Roof 130" WB 9000# GVWR w/Sliding Right Hand Door 3D VAN 6-3.71- Flex Fuel Sequential MPI Line Oper Description Part Number Qty Extended Labor Paint Price $ 1 SIDE LOADING DOOR 2 R&I RT R&I door assy 1.5 3 Rep) RT Wedge grommet BK2Z41692A 1 1.80 4 Rpr RT Door shell w/medium, high 440 7.6 roof w/o window iNSIDE AND - OUTS 5 * Add for Gear Coat 3.0 6 # Subl Hazardous waste removal 1 5.00 SUBTOTALS 6.80 5.5 10.6 ESTIMATE TOTALS Category Basis - Rate Cost T Parts 6.80 Body Labor 5.5 hrs @ $ 56.00 /hr 308.00 Paint Labor 10.6 hrs @ $ 56,00 /hr 593.60 Paint Supplies 10.6 hrs @ $ 36.00 /hr 381.60 Body Supplies 4.0 hrs @ $ 2.50 /hr 10.00 Subtotal 1,30000 Sales Tax $ 1,300.00 @ 8.2000% 1OT60 Grand Total 1,406.60 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 1,406.60 MyPriceLink Estimate ID / Quote ID: 485204504342487040/38190648 THIS IS AN ESTIMATE BASED OFF A VISUAL INSPECTION. IT DOES NOT TAKE INTO CONSIDERATION HIDDEN DAMAGES THAT MAY ONLY BECOME EVIDENT ONCE THE REPAIR PROCESS HAS STARTED. THANK,YOU FOR UNDERSTANDING. IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO SAN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS. 10/26/2018 2:51:57 PM 084137 Page 2