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i <br /> , , <br /> 11.If this dalm invoNes a vehlde acr,deni/wlllvon,provide your vchide informalian: <br /> /!'alr No. Nate Madrl Yav <br /> OdvcYs Namc DiArYs L/mnse A'o. YehkleOwrur(sJ(ilAiHemntlrwn d/fvcr) <br /> Oisncr's fnsuranre loe,pany Phorte A'o. /E�lzyNo. <br /> 12.Names,addresses and telephonc numbers o(all persons Involved In or wiMess to lhfs IndAcnt: <br /> ]3.Names,addresses and telephonc numhers of all City of Everctt employees havin9 knawledge alwut Uils Inddrnt: <br /> 19. Names, addresses and tclephone numhers of all indlvlduats rrot already identified In p1'L and f113 above who have knowledge <br /> mgarding the Ilahility I�sues Inv�IvcJ In lhis Intident, or knmvledgc of lhe Claimant's tesuhing damages. Please Indude a brlef <br /> desalption as lo Ihe nalure and eztcnt of each perron's knowledge. Altach addilional shee�If nr.cessary. <br /> I5. Describe the rause of the inJury or damage5. Fxplaln the eztent of property lass or medical, physical or menlal injuries. AHach <br /> additlanal siices iF necessary. <br /> IG,Has this huiAcn[bcen reported to law enForcement,saFery or secudry personnel7 If so,when and to whomi <br /> 17.Names,addresses and telephonr numbers of treatlng medlcal providrrs. A[lach coples of all medlwl repods and billings. <br /> IFI.hlcasc altach dowments lhat support the dalm'.allegatlon;. <br /> 19.IdalmdamageslromiheGtyofEvereltlnthesumof$, __ <br /> Thls dalm fonn musl I.a slgned by dthcr thc Claimant or on bchalf of lhc Claimanl by an attomey-In-iact who holds a w8ttcn powero( <br /> attorncy(or the Cla6nanl,or by an allomcy at Iaw admltted to pradfce In U�e State of SNashington,or by a mml-approved c�uarcllan or <br />� gUardlan ad Illcm, <br /> i dedare undcr penalty of pe�jury under the laws of the State of Washingt�n that thc foregoin9 Is truc and mrrect, <br /> ������.,� (� /'G���� Q If�� � ' <br /> Sig ture of lalmant pate Place signed(city and state) <br /> Rev,07109 <br /> �3 <br />