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Snohomish County P.U.D. No. 1 For Office t)w: <br /> Claim for Damages t> <br /> 1456 Rev. 9/96 1`+e <br /> Your wne(Include spouse,if married) Hone pheee a we*phaa a <br /> evere Gt' <br /> sum rot tarry Suits:and up code <br /> l >d7 � C.�/yAr 7�T f_VEr�'� GIkL �dXU <br /> l.entlorr of t Doe of fnddat Approxfrwn timirrn <br /> e Amount of C7e <br /> -4-c Ro/ -sem-3 /o;b A s <br /> Nemec of PUD ernploym present Qf kmwn) Witnesses,if my (nems,-44M -n,ettd phone ntanbds) <br /> W <br /> k ,p Please provide a brief descrlptlon of the Incident,Incivding any defect or action that caused your damage: <br /> y V UOh�/y ty�q Ve At0" 0 e 40 1 ArU• Corlee <br /> IV a 5 /At('- w ger e- <br /> re a GJd.if 7e a P-r- lkerpt-ems 6 � <br /> ALoe 114401 f1PA-0Jte Lill G &er-e' <br /> � ,[a '[ o er cuaeen <br /> Oe- veLcausti <br /> S S� 5r- SE <br /> 2. 7. <br /> 5, a. <br /> 1. 9, <br /> 5. 10. <br /> I have read the foregoing claim,know its contents,and believe the sane to be we. I certify under penalty of perjury under the laws of the <br /> State of Washington that the foregoing is true and correct. <br /> C <br /> f <br /> --Face- - <br /> Piour signature Titleae <br /> Instructions <br /> 1. Please complete this form and return it to the Risk Management Department,Snohomish County P.U.D.,P.O. Box <br /> 1107,Everett,WA 98206. Please return your claim form promptly,as we must receive it to process your claim. <br /> 2. if your claim involves damage to your property,please obtain at least one repair estimate and forward it with your <br /> claim. <br /> 3. Upon receiving your claim,we will immediately forward it to our independent claims adjusting firm. You will be <br /> contacted directly by them within three working days following receipt of your claim. <br /> 4, if you have questions regarding your claim or need additional information,please call the Risk Management <br /> Department at(206)258.8395 or toll free in Washington State at 1-800-562.9142,extension 8395. <br />