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11.If tfils cWlm involves a v:hide acddent/tolllsfon,provlde your vchkle Infonnatlon: L��.__ _ <br /> lYskNo P7aA�e Mralel Yc�r <br /> 7Nltrr3Name �� O�A'e.v!:lhrv+seNa UehMe�Owner(.�)(11AAlermtliomdrlrrrJ . <br /> Nf� — <br /> � UtncrYlnwdncc[lvM�nY YMnaNa /h7ryNo. <br /> 12.Names,addmsses and telephone numtrers nf all persvns inro�v�d In or wlmess[a thls Inudene � <br /> hl;�i.a�attlP. -- tlloo ls�' S�-, IV. E � Ilty <br /> _\nLS�542►n.�+n , �?C.-�-c,on � <br /> —��_�� Ph�n� '. 47 �_�lG�g=1 '-�Cs'-e.lpJanvie_L--_ _ <br /> 13.Names,aAJre;ses anA telcphonc numbcrsof all Ciry ot F.vcmlt empbyces having knowlr.dgc about thls Incident <br /> 14 /� — <br /> 1�. Names, addresrs and tcicphone numbers o!all Indlviduals not already Identlfled In N12 ard N13 a6ove wbo have knawledge � <br /> rega�dln9 [he Ilahlllty Issucs Inwlved In�his Inrident, ot knovdedyc of lhe Cialman['s tesulting damages. %ense Indude a bdef <br /> descdpUon as lo lhe naturc and e�tent of mcfi per�n's knowtedge. Alluch addi[Ional sheets If necessary. <br /> 15. D¢salhe lhe cause of the tnJury or damages. Explaln the exlen[o(propedy loss or me�Ical,physlral or mental InJudes. AtWch <br /> aAdillonal sheets If necessary. <br /> C411S_�-�D ���/J �'�!Y_1—��_LC4�1 1►� <br /> �_ ��i►.e, -�F _h�c�rc e-�IU �rrF, <br /> � cl.��rrar� r���care_, ��o � l t�ee�i rc.hc�s�,. <br /> �_ �r� llt�e�s��lec+r�r_Svn�l� � inude�.�t,15� �' <br /> ��r�_a�nre,�-�, t�intir_i_�uu�ir�-�mn�cl��v��_Irl�, <br /> IG.I las thls Inddent heen repodecl lo law rntorrcmmt,sa(ety ar semrlry personnel7 If w,when anA lo wiromi <br /> -- f�--- �- ----- <br /> 1Y.Namr.s,addresses and lelephane numbers of treating midkal providers. Attach capies of ail medical repnds and blllings. <br /> ----.. 1–Y13— -- ----- --- <br /> 1ti.PleaseattathAoamentsU�atsvpport�hed�im'SaIlc9alions.IVO uOGUVI'IC.Yt,S` (�Yl+y my WV� <br /> 19.I dalm dama9�s fmm tlic Cily of f:vcrMt In th^sum of�_ v� � ��._ <br /> Thls dahn funn must 6c slgned by Mlher thc Clalman[or on behatl of Itic Claimanl by an attomeyIrdact�Nio holds a wd4en p�weroF <br /> attamcy for thc qnlmant,or by an altomey at law admitted to pradice In lhe Shtc of Washington,or by a eourt•approved guuUlan or <br /> guaMian ad Iitem. <br /> 1 dcdare undcr penalty of perJu�y urder Ihe Wws of Ihc Statc ot Washington that the foregoing Is lnre and mrred. <br /> �Qr��.��.-1�-13_�����c�L�� <br /> Signalure of Clai ant Date Place slgned(cily and stafe) <br /> ftov.07l09 <br /> . e� <br /> ��� I <br />