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ii.If thls clalm inwives a vehicte acddent/collLslon,proNde yourvehide Informatlon: <br /> / P/utclJo. Hake Nude! Yavr <br /> N}�. <br /> Dnizr�Namc M?�^r's Ucnnsa Na Yd+klc Owncl(tJ(lldi/kicnt from dfirrJ <br /> OKnehlmvrancrComEany Phweho. PoAqNn. <br /> 12.Names,addresset and telephone numBers of a�l persons Involved In or wltness to lhis InddenF <br /> ti <br /> 13.Names,addresses and telephone numbcrs o/all City of EvcrMt employees having knowkdge aboul this Inddent: <br /> F3via�, 8�ola►, , Pu�ril�L wovl�s ��t`,_ wo CR�a+'i Ev.�a$ <br /> __}a5- 2� - 88t8 ,- <br /> 14. Names, atklresses and tclephone numbers of all Indlvlduals not already Ider.tified In Q32 anJ A13 above who Iwve knowledge <br /> rec7ardiny Ihe Iiabllity issucs Involved In Uifs inddent, or knowledge of Ihe qz'manPs rrsutlng dzmages. Piease Indude a brlef <br /> dexrlpUon as to lhe nalure and euten[of each persor.'s knowiedge. 4Kach addlyonal shcets If necessary. <br /> Jin, R�..skou�s(¢i �;s 5 sFara+ro►. ser ' s Se�.v_icg_h�..�a�✓ '+z5-�loG-6d8 I <br /> ERiC._�N,��.�,y� er's lnsuv++�+��x_ erQe-r.�,.s �42.5-�54-3va? <br /> I5. bescribe lhe cause of Ihe InJury or damages. EzplaM the eden[oF property loss or medital, physlol or meMai InJurles. Attach <br /> additlonal sheels if nece�ary. h+yp�µ �'ha Q,f,eW�r �%w �b��fi' <br /> F�on�P_ �4doAe�- d4e �I�o �w� v_n.o-fa.Q1'ed �t.eQc- Iht,2VP. <br /> C . � � ' <br /> �yp�.�Q5�_ �-ilaS�.v� �_ i•,.. cune — ---- - � <br /> �i�'tl,v-a � ' � ' > � <br /> Ln. a.o lu,�.�.n.�.e. Sen.vr.�_►�r-e9�LeL���- ►�.N�; `+A a.U. <br /> �����.C�wi� h,wA '1'1�-_d v—__vu4}�A.la�iatii. a_ - -� <br /> 16. as this incldent been repated law mforcemen[,safe or secutlty personnei7 If w,when and to whom? tl'�"T` ���' Pw I <br /> --- --,� C4.PRccQ �.v . �}' La✓ Pu.A�ci�� ttta,a �yc�f,e�i,�p {p'�v��eM�.� ' <br /> _��z �U <br /> 17.Names,addmsses and tMephone numbers of treadng medlcal provlders. Atiath coples of all medfcal mports and billtngs. , <br /> N�A .__ _ _.. --- ------ -- <br /> 10.Plea;t atti�h dacumen[s lhat su�ort thr.clalm's allegatlons, � <br /> 19.I dalm damapes from the City of E4erett In lhe sum of f�Pil � _. <br /> Thls dalm form must be slgned by cither thc Uatman[or on behalf ot tlie Oalman[by an altomcy�lmfad who holds a written power of <br /> aUomcy for the Cfalmant,ar by an attarncy at law admilted to prodicc In thc SWtc of K'a}fiington,or by a court-;+pproved guardlan or <br /> puardlan ad limm. <br /> I declare und penalty of pehury under the laws of lhe State o/Washington that ffie forcgoing Is We and wrrect, j <br /> ��3/J1�3 ���• <br /> Signa re Cialm t atd Place sfgned(city'and state) <br /> aov.atros <br /> i" _ i <br /> � 2/z � <br />