HomeMy WebLinkAboutBuilding Correspondence 1982-3-22
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&PRINGFlELD
lilTl OF SPRING1"lliLD
Finance Department
March 22, 1982
Hancock & Associate Adjusters Inc.
846 N. "A" Street
Springfield, OR 97477
Attention:
Subject:
Gary Hancock, Adjuster
Slip-and-Fall, SP-82-182- Lesa'M. Dahle
Dear Gary:
Attached, please find incident Report, concerning a
by my office. Please open a file and investigate.
as to any progress concerning this claim.
slip-and-fall claim received
Keep my office advised
Thank you.
Sincerely,
JI~~
/ Sharon Miller
Risk Analyst
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Attac~ment ~
cc:~ike Kelly, Public Works Director ~~~
Ed Harms, City Attorney
Don Loomis, Attorney
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225 North 5th Street · Springfield. Oregon 97477 . 503/726-3705
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INCIDENT 'REPORT
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INSTRUCTIONS:
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Time //:t/S ~
O~te of Birth /-5- 0/
FILL IN EACH BLANK THAT APPLIES. PLEASE PRINT.
Date of Incident '-jJztt/u./; .3 - g;)..
Name of reporting person ,~~~ ~--
Address J~ ~ tj N :s t
Telephone 147- 0 /4 1- , Business Telephone
Name of injured party 2.!:. owner of damaged property IN FRrJ 1-1 r 0 F
GDod tv / II S to f'e-
Address .;< J ~ Jnt'LUn
Telephone
1L/0 - 9073
Itemize damage and/or injuries
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Exact location of incident (be specific) A B,o L1'- b F r i 17 i},/YG / e...
_To ihe Ie F t 0 F the. (rod! Do{)~,
Briefly descri be exactly what happe-ned 00 t t) l{ -r p F (2. It e I-ilid
\Jt1 '5 tJ Il, j/(/rI c;, 0 W fttj~ fNtR/tNCe- &/ G~dJ W;I/
sto,,~. SI8- p,peJ witA MY ht!.e / Iff. iA"::i 'SLt/v'KEN
BloC/k c F Slci ElJA-lK. 7Ut~~J M/ ftt{){'!e. .y Fe /!
To whom was incident reported? D.i<. jf100 8'50 1'1
Was the Police or Fire Department called? Yes 1( No
Names and telephone numbers of witnesses ~u J fI ~II, 'E is r: 12
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