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1I.]f thls daim Involves a vehlGe acddent/�llis:on,pro�Ade your vefilde Informatlon: <br /> MMeh'a Afud�e Mo�el Yedr <br /> arh�cYSAt�mc DrHrofrL/censeNo. � Ve�JdeOKv�cr(sJ(!AI/lcrenlfiumdnverJ <br /> O�mn's/nswanroCompvny PhoneNn. � PoliryNo. <br /> 12.Names,addresses and belephono num6crs ol all persons involved�n or wlinr.ss to ihls IncldcnL- <br /> l3.Names,addresses and tclephone numhers of all clty of Evcrett employees hatiing knowledge about tlds Intldent• <br /> 14. Names, addresses and telephonc numbers of all Individuals not ahrady Identl8ed In ft12 and A13 above who have knrnvledge <br /> rcgardin9 lhe Ilabllily Issues InvolveJ In lhls InqdGic, or knowlcdge of the ClalmanCs rr.sutUng damayes. Please Indude a brlef <br /> desttlptlon as to the nature and c�henC o�each person's knowledge. Allach addiNunal sheels if necess3�y. <br /> � I5, Descdbo th�caa,e oF the InJury or damages. Er.pfaln the eMent of prope�ty loss or medlcal, physical or mental InJurks. AUach <br /> addltlonal sheets If necessary. <br /> bacl<8ow(n basement drainage resulting in black water ilooding in basement. little damage except some <br /> throw carpets and air qualily <br /> ; <br /> � 1G.Ilas this Inciden[6een reported to law cnPnrcemcnt,sifcly or seanlry persom�elP [f so,wl�en anJ t<i whomT <br /> ' to pubHc works <br /> 1%.Name.,addresses and telephone numbers o(healinp ineJlcal pmviders. ANach coples of.II medlral repmL^and blliings. <br /> 1 R.Pleasc atiach documents that suppat the datm's allegatlons, <br /> 79.1 dalm damapes from lhe G�y of Everett In thc sum of¢ �00 <br /> Thls clalm form must be slpnM by either the dalmant or on behalf oF Ihe Clalmant by an nllorney-Imfact who holds a wri@en pm�•cr o( <br /> � attomey for the Clalmanl, or by an attomey a[law admlltal to pradice In lhe 5[atc of WasLln9lmt�or by a cntnN.pprovc�pimrdian or <br /> guatdlan ad Iltem. <br /> ]dedare under penalry of pehury under Iha laws of lhc Statc of Washington lhat the foregoing L Uue and wrtect. <br /> � <br /> Kevin Riddell ����� 9/1 4120 1 3 Evorolt,wA <br /> Slgnatureoftlaimaut � Da[e Placesigned(cltyandsWto) <br /> RaV.07l09 <br /> ��� <br /> /��?, <br />