HomeMy WebLinkAboutLW07-362 - Original - State Farm Insurance - Gross, Laudis W & Ruth E, and Tom Anderson dba Release of Claim - 12/10/2007 Records M �eme
KENO Document
�/I�A9 H 1 NOTON
CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission to City Clerks Office. All
portions are to be completed, if you have questions, please contact City Clerks Office.
Vendor Name: %nY/ ZfitQ Vendor Number:
JD Edwards Number
Contract Number:
This is assigned by Deputy City Clerk
Description:
Detail:
Project Name:
Contract Effective Date: Termination Date:
Contract Renewal Notice (Days):
Number of days required notice for termination or renewal or amendment
Contract Manager: —T Department: 19411
Abstract:
S Public\RecordsManagement\Forms\ContractCover\ADCL7832 07/02
Release B,arcode Only-
47-M162-682
For the Sole Consideration of Claim Number
Three hundred fifteen thousand five hundred fifty-seven and 061100......($315,557.06) Dollars
the receipt and sufficiency whereof is hereby acknowledged, the undersigned hereby releases and forever discharges
GROSS, LAUDIS W& RUTH E , and Tom Anderson dba Fuel Tank Installation Co Inc.
their heirs, executors, administrators, agents and assigns, and all other persons, firms or corporations liable or, who
might be claimed to be liable, none of whom admit any liability to the undersigned but all expressly deny any liability, from
any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, and
particularly on account of all injuries, known and unknown, both to person and property, which have resulted or may in the
future develop from an accident which occurred on or about the 22nd day of December 2006 (year)
at or near 27830144TH AVE SE, KENT, WA
This release expressly reserves all rights of the parties released to pursue their legal remedies, if any, against the
undersigned, their heirs, executors, agents and assigns.
Undersigned hereby declares that the terms of this settlement have been completely read and are fully understood and
voluntarily accepted for the purpose of making a full and final compromise adjustment and settlement of any and all
claims, disputed or otherwise, on account of the injuries and damages above mentioned, and for the express purpose of
precluding forever any further or additional claims arising out of the aforesaid accident.
Undersigned hereby accepts draft or drafts as final payment of the consideration set forth above.
"Washington law requires us to notify you of the following:"
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the
purpose of defrauding the company. Penalties Include Imprisonment,fines,and denial of insurance benefits."
In Witness Whereof, S�,t,' � � ® J vl� nf-Lt bt;: "
48- h,4A hereunto set Np hand(s)and seal(s)this day of 8 '-le- , (year)
In presence of.
el m Signed
Witness
Name
Signed X
Address
Name
This release is translated into Spanish for the convenience of the reader. However, in the event of any difference
in interpretation, the releasor who signed above hereby agrees that the English language version controls.'
104077 7 Printed in U.S.A. Rev.02-27-2007
Page 1 of 2
STATE FARM
State Farm Insurance Companies
INSURANCE
O
Bothell Operations Center
PO Box 437
November 21, 2007 DuPont, WA 98327
Toll Free-800-489-1893
Fax- 888-251-6069
Civil Division 2 City Of Kent
Attn: Tom Guilfoile „
220 4th Ave S
Kent, WA 98032 NOV
RE: Claim Number: 47-M162-682 KENO 'LWDEPT
_ Date of Loss : December 22, 2006 _
Claimant : Civil Division 2 City Of Kent
Insured: Ruth Gross
Dear Mr. Guilfoil :
This letter confirms our recent telephone conversation, at which
time we discussed a resolution to this case . The settlement
offer discussed included full payment of the NRC invoices, plus
$30, 000 toward the City of Kent' s overtime costs .
Please review this offer with the appropriate attorneys . I look
forward to wrapping this matter up with the City of Kent .
I have included a release form for your convenience. If you have
any questions, please call .
Sincerely,
LfL� S
Christine Heinrich
Claim Representative �Z/7�o7
(425) 892-7423 C01 Mlf
State Farm Fire and Casualty Company T
Enclosure : release
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