2809 GRAND AVE 2022-04-18 - Laserfiche WebLink

TORT CLAIM FORM Rev.07/09 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), this form is for riling a tort claim against the City of Everett. Some of the Information requested on this form Is required by RCW 4.96.020 and may be subject to public disclosure. The City Clerk Is the Clty's designated agent for the purpose of receiving claims. Claim forms cannotbe submitted electron/cally(via e-mail or fax). City of Everell Use Only RECEIVED SEP 12 2013 r WY OF EVERETT City clerk ('try Clerk Claim No. t)12 1 - I LE A? i.._ E PEJOR Rf1If�TiCLEA �� Mail or deliver original signed claim form to: Business Hours: Mon. — Fri., 8 a.m, to 5 p.m., Pacific Time Closed on city holidays CLAIMANT INFORMATION: 1. Claimant's nar . Office of the City Clerk City of Everett 2930 Wetmore Ave., Ste. 1-A Everett, WA 98201 Sentry Credit, Inc fSentryPartersLLC) Last name first Middle Date ofb/nh (mr7r/ddl"W) 2. Current residential address: 2809 Grand Avenue EverettWA 98201 3. Mailing address (If different): 4. Residential address at the time of the Incident (If different from current address): S. Claimant's telephone number: 425-257-9500 _ 425-257-9500 _ Home Cell Duslness 6. Claimant's a -mall address: i,gtewart@sentrvcredit com INCIDENT INFORMATION: 7. Date of incident: 08/30/2013 Time : 6:00 a.m. ® p.m. (check one) (mm/ddlyyyy) 8. If the Incident occurred over a period of time, date of first and last occu(rences: from: 08/30/2013 Time: _6_ a.m. 6 p.m. (check one) to PRESENT Time: a.m. p.m. (check one) (mm/cidlyyyy) (mm/dd/Yffl) 9. Location of Incident: Washington; Snohomish: Everett; 2809 Grand Avenue Sbte and county city, if applicable Place where occurred 10. If the Incident occurred oil a street or highway: N/A Name nfsfreet 0rhlghway At the Intersection w/Br or newest intersecting street l/