2301 CALIFORNIA ST 2022-04-13 - Laserfiche WebLink

11. If this claim Involves a vchlcic accident/collision, prov de your vehicle information: __ __ Aa�Y Ab. PfaAr Mndel Year OrM^is Name lkA2vY Lkrnsr No. YM/de iT»xr(sJ(i/d��'�emnf bmn drhrrj OrnmcrY In axancr[ary.dny . . Pbnne Na. Po/'xyNo. --� ---- 12. Names,a�dresses and telephone numbers of atl persons Involved In or witness to thls inda>nt: � � ` ._�_.�__— --- � _ -- - -- - ---rt�'�. �'��t�''�c r � ---- -- 13. Names,addi esses and lclephonc numtx�rs o(atl City of Everett employees having knowiedge abou[thls Inddent: ��C �M�'i�� ir1S�_--�S�On - , ]4. Names, addresses and lelept,�nc numbers of all individ�als nr;almady Identified In �I12 and Ai3 abrne who have knowledge re9arding the Ila6ility Issues Involved In this Incldent, or kne:vkdge of Ihe Galmant3 rcsulUng damages. Please include a 6rlef descrlptbn as to the naNre and eztent of each person's knowledge. Attadi additional sheets If necessary. �� I I5. Deuribe the ouse of the InJury or damages. Explaln the exte�t of property loss or mediral, physlcal a mental Injuries. Attach additlonal sheets if necessary. �� �— ,� /'� ��OT,.q`�-C��ti. 16. Has lhls Inddent becn rqaRed to law enformmenl,safety or security personnelt If so,when and to wlwm7 r l7. Names,addresses and[elephone numbers of treating medical providers. Attadi copies of all mediol reports anJ blllings. ��' 18. Piease attach documents that support the daim's allegatlon� ` 19.I dalm d^�ages from lhc Qty of Evcrclt In Lie sum of�__[_O .l�.e e-� , ltil�- �`�^-`� u"-"" `t"� ' /� / P Tlds clalm fomt must be signed by cithcr thc tlalmant or on behalf of the Ga)mant by an alWrney�ln-fatt who holds a wntten power af attorney for lhe CI�I ant,a an attomey at law admitted to pracfi�e In the State of Washingtnn,or by a court•apprwed guardian or guardlan ad I�( 1 declarc u der pe alty q ry undcr Uic laws o(the State of Washington ihat the foregoiny Is hue and mrreR. / Slgnat ai Date Place signed(city and state) Rov.0710 : �� ' ��