5030 RUCKER AVE 2022-05-13 - Laserfiche WebLink

] 1. If thls daim Involves a veMde accidentJmllision, providr your vehide information: _ _ R'afe No. Flakc Model DAve/s hame Dn�r/s [Iccnse A'a. �chide Owner(s' (.�'di/fert+�t ham diiverJ O�r�ner's Insura�xe Lompan�� + R'iax No. Policy l.b. 12. Names, addresses and telephone numbers oF aU persons Involved in or witness to this incident agnieszka A Myalak A25-427.-8786 5030 Rucker Avenue Everett, Wa P9203 Juhliette Genlzler 425-308-0142 .5030 Rucker Avenue Everett. Wa 9820: Marceil Gentrler 425-446-1793 5030 Rucker Avonue Everett. Wa 982D3 t3. Names, addresses and lcicphone nunilxrs of all City oF Evr.rett employees having kno�vledge aGout thfs incident: 14. Names, addresses and Mlepfione numbers af all mdividuals not already identlfled in K12 and F13 above who have knowledge regarding the liability Issues Involved In this inddent, or knowledg^. of lhc qalmant's resulting damages. Please indudc a bdef desuiption as to the nalure and e�tent of eadi person's knowledge. A!ach addilional sheels if necessary. 425317-8781 5030 Rucker Avenue Everett, Wa 98203 Myslak 425-317-8'/Bt 503D Ruckcr Avenue Everett, Wa 98203 Radoslaw Myslak 425-320-7581 5030 Rucker Avenue Everett, Wa 98203 15. Describe the cause of the Injury or damages. 6cplaln tlie eMent of property lass or medical, physl�l or me�tal inJuries. Attach additional sheets If necessary. The basement of my home was flooded fram water coming out of Uie shower drain. The extenl of Ihe damagc is 2 bedrooms, bathroom, close!, storage space, lower tanding and stairs. As well as office fumilure some chairs all carpet and lower part of �valls in the basement. ServicoMaster came in and taboled Ihe extent of the damage as level 3. Juhliette Genlzler and Agnieszka Mysiak have been having sore throats since the inGdent. 16. Has [his incident heen rr.ported to law enforcement, safety or secudty personnel7 If so, when and lo whom? 9I3/2013 - ServiceMastcr 1 Mall Davics I 425-353•55�G / 425-7b4-1220 ] 7. Names, addresses and tclephone numheis o( Geating medital providers. Attach copies of all medlcal 2por� and billing,. ld. Please altach documenLs that suppod the dalm's alleyations. 19.1 clalm damages fwm the City o( Everelt In the sum of $�o�C00+ ThL daim form must bc signed by either thc Clalmant or on behalf ot the Claimant by an altomey-imfad who holds a�t�ritten powcr of attorney for lhe Clalmant, or by an altorncy at la�v admil�ed lo pradice in lhe State oF Washin9lon, or by a wurt-approved guardlan or guardlan ad Ltem. I� ciam under pe�alry Of p ury under tlie la�vs of 1he State of Washinglon that the furegoing is true and correct. l 1 c �� 9/312013 — — — — — -- ---- -- - — — -- --- Signa e of Clalman Date Place signed (city and state) Rev.07 9 � j2�2: