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11.If thls clalm Invalves a vchlcic acddent/calllslon,provide your vehlcle informatlon: /v /� <br /> PlatrNa MaAr Mode! Y�� <br /> Dnvr.Ws Name OdvnS[lmisc AD. l'ch/de Owncf(s)((diRercnt�rom ddYrrJ <br /> Onne/sln!vrarmCbmpany � PlroeeNn. Po!lryNo. <br /> 12,Names,addresses and[clephone numhers of a�l persons Involved In or witness to lhis inddenl: <br /> IZ+�tie,r�' sme.e.r LkZS - � 12� `�r�s�-{ <br /> _ Loa�G- -►-���fe�� 2_06 - �t-2o •- 9 3 6 0 <br /> 13.Namcs,addresses and telephone numbers of all Ciry of Evereu employees having knowledge ahout this(ncldent: <br /> ►���:�i4°47j MiE',.!% 4�t2'Nflf�Dt � L�i:1�� Pc�l-�Ct; DF�=iG�� <br /> � <br /> 14. Names, addresses and telephone numbers of all Indivldu3ls no[aiready Identifted !n 1t12 and Jt13 above who have knowiedge <br /> rcgardtng Ihc Ilabllity issues Inwived In lhis Inddent, or knowledge of the Clalmant's resultlng damages. Ple�.;e Include a bdef <br /> desalptlon as to lhe nature and exMn:of each person's knowledge. Attach additional sheets if aecessay. <br /> � <br /> 15. Describe the caus�oF the InJury or damages. Explaln :ho e�ctent of property loss or medical, physlral ar mental Injurirs. Atlach <br /> additianai aheets IF necessary. <br /> n A _u 3 ��,� u.as .�eav i . 'n ��e�lr s�rwu- tilE..r.�� c�-u scq� <br /> '�- aur t,v Lr�n- b�(�rnPh,� — I t t. i; e -f�c-ri <br /> � ic 2h/ /�„ -S a n, c.-.('na � �mn � .�po r c,'r <br /> �(�.], h-G1�.� GLI�s� �f$171Y�I �U�"�-.$ e / <br /> �—�_—. '— <br /> I6.Has ihis InddenC 6een repoMed to taw anforr.emenq safety or security personnel? [F so,when and to whom7 <br /> —� �� <br /> 17.Names,addresrs and teiephone numbers of treatlnp medfcal proWders. Attach mples of afl medical reports and hlllings. <br /> J�o�� c-;�.t.� u��-ur�,_ . <br /> � <br /> �e. please ittach Aacumenls tlmf supporC the cialm's allegations. U,.-� <br /> Q- � <br /> 19. t clalm damages from the City of EvereK In the sum of; v0� _ <br /> Thls clalm form must he signr.d by either the Galmant oi on bchalF oF lhe Clalmant hy an atlomeyIndad wha holds a written power oF <br /> attorney for the Claiman[,or by an aHorney at law admitted ta pradice In lhe Sta�e of Washington,or by a courtapproved guardian or <br /> guardlan ad Iltem, <br /> I decla under penaity of perJury under the laws of tha Stato of Washington that tho foregoing Is tme and cartect. <br /> ���Z��l�� �1�-�f ) �3 l�s 20 `�CZ�Dv�fl'� ��)��Ci� <br /> Signa ire of Clafmant� �e Piacesfgned(city an state) <br /> Rov.OT/09 <br /> .� '` <br /> � <br /> j �.-� � <br /> <�-���o � � <br /> I <br />