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i <br /> i <br /> � <br /> 11.11 lhls cla4n Involves o vchkle actldenVmlllslon,prmlda your vrhldo Informatlon: N�n <br /> Fll�1cNa. Mt,Fe MaeFl Yivr <br /> aAerSName '__—. .� WM1ror4lkenseAb. YN.'OnOwrMr(t1(Nd�Mnenflmmdrlcr) _ _____'_ <br /> '— . _.�'_—'___... .___�___..._. _ ...___ _.�'�._ '. ' . ' <br /> OHnntlnrwincr[M�oe�ry � PlwnoAa N.YryNa <br /> ]7.Numes,adAresses end telephane m�mMr�ot el persons Involved In orwttnwslo lhls Incldcmh . <br /> C�e,.. P,�l,�,,. 2n(. • 9 vo-'[�'04—_r.�=c�a1�:_ �-�.:� c�z 1=4z:- �ii5(.__ <br /> ..Ln-a:-.�l�l..�\ ��i"- �(a7-_7='�-----��c.. . al ar�,� � �17�-�?I��- [/39i�_ <br /> ICYcC�]LP.�C?£ f t� �- 7zo - Gi7�6f ----- --- <br /> . 13.Namas,uddresst;onA tdephone numbcrs vf a6 Oty of Fwrett Pm�loyen:haNnp knovAcdpc ahout lMs InclJenL' <br /> � __��Y1�N��4__ d I CI �.,_�(MN'OI��CCS. <br /> 1 Y '_. .____ ._ _ _" . _ <br /> 19, Names,addmsas and lekphoiw num6em of all IndivNuals rwt etraady IdmtlfHxl In Al2 and t13 ebovo who heva keovAqlgo <br /> rcgarAing the IiaMNty Issues InvoNed In Ihls Mxldmt, oi krwvAcdgu of the Cla!manCs resulting AamaAes• PNasn IndiNe n 6rle� I <br /> descrlplbn es to the natuN aM!ettmt W wch person's Imo�NeApe. AWich adAltronal sheeL If nece.sary. <br /> — — Ni/} --- — - .. , . _. .. _ <br /> l5.D�crl6e the auso M Ihe InJury a damaga. l:�laln tho oxlent of Mo{nHy Ios�or medkal,physlcal or mmtel InJurks. Attach <br /> oddttional sheels�f necessary. <br /> � ��nk 4�'�-!1__.�At.�S-�.._U�II:`'4t[- p...fL_=c'...���' �n►�ka�C___�_n ew� <br /> •-CAu.�r..._t,_vY"_O.F_ __���-6. -1..�.�.a.:k.ti_ � LLf+i.�iA�.L'__�.a—�S.�r_.�Ac.CS <br /> -lL.t_.�1J�__�ol�l,.Sn....,..4 A� �' �.11_�'.n�., �-o..+.+i'-.f�--. <br /> _g��n . -fl..,a_._ F�-Syuv. _..I3c`_.5�1,�1',•nr�1�,-1ou�,4�lt---:.�... �.l Ms�•c nw� <br /> ._1.-�C I>.re,.__S 1•��o�-:i�+'-^�_��_._(J�:.�f �i...e ll. ---- <br /> IG.I las Ihls inddent hmt reDodeJ lo Inw enforcemen4��ely ur m�atlty perwnncl7 If su,wlxen mJ lo whomi . <br /> . ��v�=��_ L�I'7-e��p..I��..S H''c .a1_wq.r .r{- AVc'-.A F�O��i. AN S<G•v. <br /> -" "_ ' _ `1t�o�fi. �. <br /> 17.IJdmus,n;IJresirs ond tal�hnnn numlx!rc e�f�enUiw medlcal providers. Altndi coplee ol all medlcal rupats nnd blllings. <br /> � -- -r/.�—__------- — '-- <br /> IP.PlcaSe allnch dxumenL+Omt supp�d thu dalm's allequllons. � <br /> �l. <br /> i 14.1 cl�lm damanw hum Uir.tlty of Evirctt In thc sum of s�,� �5/ ___ I <br /> Thls clapn fnrcn mus:bc�gnod by cllhcr ttro CJnlmant or on twhalf of the Clalmant by an ettomuy�lmfact wlro holdr e wdtten pnwnr of <br /> ixtlomey for fhc Clulmant,or hy un allorney M lan admitled W prxtice In ihe State of Washlnptnn,or by o rourt�p�roved puardlan or <br /> I puardlan nA Illom. <br /> � f rkcl m unAcr penalty al�nJury� dm lhe laws of lhc Slptc of WashingLon Ihat Ihc faro9ah01s Uua nnd mnaU. <br /> � �� ��� <br /> I ���r'���..�-� 4��- - -�'��,-�a__ � <br /> 1 Ignaturo at Ga mant U IO PI0C0 6IgtlE� �CII�Al1II6[BCB� <br /> � pev.WJOB <br /> � <br /> r. . <br /> "� <br /> ali � <br /> �_ <br />