2908 90TH ST SE 2018-01-02 MF Import

Snohomish County P.U.D. No. 1 rrroffice the: P� o Claim for Damages D-- 1456 Rev.9/96 Due Your none (ispouts. (includeif mined) — —_ Hams phone a de pho ne a c i� n oATv ` u�i 1t ��__ Ks7_ew Sued address City Sum and op code c:o C Lade Ufa. 4$ `45 I.ou�ion of Indga�t Due of (nddmt Apposimm i Arno nt of Own e( �IOQr 1J0 .s/r 5, l� DO Names of PUD employees pmon (if line") Wititndmr, if my (omen, addresses, and plane nuabm) E Please provide a brier description of the incident, including any defect or action that caused your damage: 5' s aal� r'n lac 1` P•T �' - t�ur� CC, StAy ��(j/ uw /0C p[ E old / p0 vC r Aev ec 11fe O I&YO ct it to Pole Cr w 4& 'C.& 71 a 111— e r Lo fu12tAtP no o Cdl tKle Pet OkS [':A �/e eza 1— �j- rr — o ►"e r ( U' v It Q. 04C wG AL ., INf I r'A ?` N�.ef out r. ), 6. 1 7. S. a. 4. 9. S. l0. 1 have reso the foregoing claim, know its contents, and believe the same to be true. 1 certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. S Date Place Your signature Title Instructions 1. Please complete this form and return it to the Risk Management Department, Snohomish County P.U.D., P.U. Box 1107, Everett, WA 98206. Please return your claim form promptly, as we must receive it to process your claim. 2. If your claim involves damage to your property, please obtain at least one repair estimate and forward it with your claim. 3. Upon receiving your claim, we will immediately forward it to our independent claims adjusting firm. You will be contacted directly by them within three working days following receipt of your claim. s 4. If you have questions regarding your claim or need additional information, please call the Risk Management Department at (206) 258-8395 nr toll free in Washington State at 1.800-562.9142, extension 8395.