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Snohomish County P.U.D. No. 1 <br /> ��ar�uk: <br /> Claim for Damages a <br /> 1156 R�v. 9/96 � <br /> Yoor �� <br /> f�� J �a� <br /> � C A e/ �. (il.r..� C�' a �7; ,` � xamepha�er WS —$�(e.� <br /> Suaet dd�s� G�Y SWe ed ap oode <br /> � oo Ce ,. �'iT,' Eu er e Tt� � o / <br /> Lo�tiaa of• ' Mte ot mdde�t Appro��e�e Amou�c of CLim <br /> 5'o i 2 .►s�toc.r i' • �li' -'4 .ov .�Y. ? S <br /> N�mndPUDa�loyas (Jkrown) Wiuieae�.ifo �uma,�dditun, <br /> Y ( odpAaoenmihen) <br /> Wa ren rr 'er � / <br /> � • Ptame p►ovtAe a 6rietdesrrtptbn of the incideoy including any dekct or acNoo that caused your damagr. <br /> � Ll� ¢ oo Cct l`c� �NeN �'Erv�G ��h tvi e <br /> � � re n � CHt Q m a7� r � Q7��2r• <br /> S eN <br /> � <br /> • • <br /> �nv .�a� ' <br /> �. vr. <br /> G <br /> 2 7. <br /> 3. & <br /> !. 9. <br /> 3. 10. <br /> � I trve�ad the[rneQoinQ c��im.lmow its contents.and believe�he same to be true. I caafy utda penalry ot pujury under the lewa o[Ihe . <br /> Sureof WWnneron that Ihe forogoing is true and cortcec <br /> � '7� � <br /> � � Place -1`- �� 'C/G�zi�'/ .� <br /> Your signawre ��e <br /> Instructtons <br /> 1• Ple.ase complete this form and retum it w the Risk Management Departmen4 Snohomish County P.U.D.,P.O.Box <br /> 1107,Evuet4 WA 98206. Please retum your claim form pramptly,az we must receive it to process your claim. <br /> � 2. If your claim involves damage to your property,please obtain at least one rcpair atima[e and farward it with your <br /> � claim. <br /> � 3. Upon roceiving your claim,we will immediately forward it to our independent claims adjusting Fum. You will be <br /> contanal directly by them within three working days tollowing receipt of your claim. <br /> 4. If yo�have qucstions regazding your claim or need additional information,please call the Risk Management <br /> �P���az(�)ug-8395 or toll free in Washington State at I-800-562-9142,extension 8395. <br />