3515 WETMORE AVE 2016-05-27 - Laserfiche WebLink

11.If this claim involves a vehicle accident/collision,provide your vehicle Information: Plate No, Make Model Year Oliver's Name Driver's License No. Vehicle Owner(s)(ifdiiferent from driver) Owners Insurance Company Phone No. Policy No. 12.Names,addresses and telephone numbers of all persons involved In or witness to this incident: Far)vi C C.s-- 1-125-3 q- 1410310 -- kfvil?.VVb a :3515 ottrvibYt, AV' .1)viU A 00rivlit Tfr s - 4425-32i . 014013-U1artev s j..ls t 4wmorc Avr . At i3 ` atios -Hum- - �125- 629- !L421-1 - Ot vwr o- Uwtl- A 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this Incident: l coped r 1-77 )wit 1-164.fr,Ptibltt iA)ot'lo Svp vv} ov' -7,00 Ayr C! twplotyrG'.s — CLwU Ad} Vl'I' F of lint iwittd(04, bi Swuis raect5 iw.fp(chect air �} CtrAlal sp r(s. 14. Names, addresses and telephone numbers of all individuals not already Identified in #12 and #13 above who have knowledge regarding the liability issues involved in this incident, or knowledge of the Claimant's resulting damages. Please include a brief description as to the nature and extent of each person's knowledge. Attach additional sheetsif necessary. Vl��gtt�(will. 04/. 4-tA 11) 04)3Aid o� Uw'4k p, ri, d _4pc+�icu�, FI - ~ E 2 - 15. Describe the cause of the injury or damages. Explain the extent of property loss or medical, physical or mental injuries. Attach additional sheets if necessary. AVIV er 2411v 4)41.1 it tal exiYervc real , •I'tt 'Joky aid s way go¢ so bacto rr� %A+ WAM 01)ti ,r (Yi WA all cefikupceus ( dUr J-Vkk f Cthdowfieirwii COtmpi(x. Ike W6.4-te A1s0 CpVscr 0U( 5id(waitt'- to sivAc z'I fitf is i,ki9 aln `fuc Mnri evil 'file l�utldly . 16. Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? Gii-y 4 Eettl1 was nolificd aocl cawic n11141- iti ivispecf Critolspou5. 17. Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. 18. Please attach documents that support the claim's allegations. 19.I claim damages from the City of Everett in the sum of$Uht,i4O14314- St( ailtdAtri does This claim form must be signed by either the Claimant or on behalf of the Claimant by an attorney-in-fact who holds a written power of attorney for the Claimant,or by an attorney at law admitted to practice in the State of Washington,or by a court-approved guardian or guardian ad litem. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. 441/46/6* lv Tit 3 6V C I, WA - Signature of Claimant date Place signed(ci ty d and state) Ray.07/09 f /