2530 LOMBARD AVE 2022-05-25 - Laserfiche WebLink

11.If this claim involves a vehicle acddenVcollision,provide your vehicle information: Plate No. Make Model Year Driver's Name Driver's License No. Vehicle Owner(s)("different from driver) Owners Insurance Company Phone No. Policy No. 12.Names,addresses and telephone numbers of all persons involved in or witness to this incident: Chuck Morrison 425.740.2323 all are Red Cross employees Lelia Irvine 425.740.2314 William Burns 425.740.2317 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this incident: Email sent to City of Fverett Public Works (Dave Davis) on 8/30/13. 14. Names, addresses and telephone numbers of all Individuals not already identified In #12 and #13 above who have knowledge regarding the liability issues involved In this incident, or knowledge of the Claimant's resulting damages. Please include a brief description as to the nature and extent of each person's knowledge. Attach additional sheets if necessary. 15. Describe the cause of the Injury or damages. Explain the extent of property loss or medical, physical or mental Injuries. Attach additional sheets If necessary. Flooding caused by the rain storm event of 8/29/13. Water backed up through all piping (sinks, toilets, etc.)and reached a level of approximately 5" throughout the first floor of our office building. The water was a mix of storm water and sewage. Property loss/damages include: wood furniture; some files; moulding; drywall; carpeting; IT equipment; etc. 16.Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? Incident was reported to City of Everett Public Works on Friday, 8/30/13. 17.Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. N/A. 18. Please attach documents that support the claim's allegations. 19. I claim damages from the City of Everett in the sum of$ 1 bd . This claim form must be signed by either the Claimant or on behalf of the Claimant by an attorney-in-fact who holds a written power of attorney for the Claimant,or by an attorney at law admitted to practice in the State of Washington,or by a court-approved guardian or guardian ad litem. I declare ii c r penalty of perjury under the laws of the State of Washington that the foregoing is true an correct. ` geile Ve_fell) bLiA- • . Sign lure of C aimant ate Place signed(city and state) Rev.07/09 i I /n )