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lt.ll tNs clalm InvoNes a vehide aai4cnVco��lsinn,provl�e wurvch;dc Information:_ _ <br /> P/afc Nn. l.lake MnGI Ynn <br /> Odr.Yi Name d+lsik[irenre No. Vrh/rkOwnu(i)(JdJTarM/mm drAstJ <br /> Ox'ne�slnnimrreCnmpany / neAb. _-- PoGryIYa <br /> 12.Names,addreurs an�0 rtclr"phonc rmm6crs o persons Irnrolved In cr wilriess tn Uns Indden[:— ��o��N¢ � <br /> ��w -t"�w — �-lzs-�-5:2- _�31 ( �Nzs-B'�c>—`f7Fs5b <br /> 13.Names,addrsses and teleppho�ne numtm ot all C�ty o(Evelet[em-p'loy`ees hadng knowledge_about tAls InAden[: <br /> --CW"�tiC_ U_.�.14�`0✓, ��, � �j+�T�'—��V-I.a—DU'�(A-�31Y�SS _ <br /> —..`.���01'�T�-�—,-��-�--- ' <br /> --- I <br /> 14.17amrs, addresses and tdephone numben ot afl IMINduals not aheaAy IderRlfled In#12 and 7tt3 abooe v.fio have Imowtedp• i <br /> rogarding Ute liablllty Issues Inwlvee In thls IMdent, or ImovAcd4'e of the ClalmaM's raulOng damaget flrase Induda a MIeF � <br /> descdptlon as m the nature and oQent of eaoh pvson's krwwkGge. Atta:h atlfitlonal sheets If necessary. <br /> I5.Deserlbe Ne cause of the In;ury or damages. F�Ialn tlie e�Amt of proprrty loss or meiKal,physlwl m mental InJurles. AUach <br /> addlnonai sheets if necessary. ,./� <br /> _�j IC W F.�L W� —��� _�n.�_—I ��—I O�f.k.. k�,.,� ��� � a� il . <br /> ---�Q ` � � _��7 fL'GJ4- U Y�C�I/...0_Ctd/�!—�i�T� <br /> O_ 51 _Q��4�f��� .�/� ` � _ <br /> ' 2 G. a�'U rfl te� __`L�2v u.�_f�i�f/oM <br /> —_- S__ ��_Q�_f�.^_j'}`�l'Q�lh'��M e�r n fl'GY� s'Lr��'�/G1f..� <br /> 1G.Nas Nils Inddent bem reportat to law mforcement,sateq w saurtty personncl7 If so,whcn anC to whom7 T•0�� <br /> _� — <br /> 17.Names,addrtsses and tele�honc numtxrs nf Uealing n�ediwl providers, Attadi mpMs af all mMlrai rc{�orts and bGlings. <br /> ��" _ —___ <br /> 10.Ploase altach documens lhat suppoH Ne clelm^s all�atlons. � .� <br /> 19.I dalm damapes fmm Uie CILy of EvcreU ln lhc sum of���(`�}'tVM_�e�(/o'(�5 t.t.r� <br /> This dain rortn must bc signed tr/etthcr thc Clalman[or on bchalf ol thr.Clalmant by an altomeyin-lact wh o�wAttm powcr o! <br /> attmnry for the Clalmant,or Uy an attamcy at taw admlttecl to praclicc In thc Statc of Washinglnn,nr by a crnn�apprnval�vaM;in ar <br /> guarclwn aA lilem. <br /> 1 ckdam unJcr{�alcy of pe�Jury w�der Ihe laws of ll�e Slale of VJashingron Uiat lhc fomgoing Is Wc and mrrect. <br /> ��� l,�c��4Y — ---9/z.��l����"���°2,� <br /> SlgneWre of Clal nt Da[c PI oe slgned(city end state) <br /> nev.ono9 <br /> �-.-1 <br /> a�a' <br />