Laserfiche WebLink
11. If thls claim Invoives a vehlde actident/wIIlslon,provide your vchicle tnlortnalion;___� <br /> Pa1eNn. M1fa�Ir Madrl Ycar <br /> Onvrr'sName ATxr�Lirn�srM1'o. ��.'rleOxnen's)(ddiPErrntlrvmdnuerJ <br /> Oµna.�'sJnsu2nrc Campany Phanr A'o. Po/ityNo. � <br /> 12.Names,addresses and tplephone numbers of all persons InvoNed in or vrilness(o thls IrrcldenL• u�j�7G-�/,�// <br /> ���'��Y-�t�o4�1._e�wm.st,//�y2& sw,�.m,�'z ,2�.., rs�.,l,.�,.rz cv1�- 9d'al� • <br /> -��nr-�tad�eJl��ns.rHt,eu�//•1��'�lv�»�.(7,.,avs�ia�mi�_wr4_._��a-Sb-.Z4�F�.�T.1 Y <br /> 13. Names,aJJmsscs and ldcphoae nwnhcrs of all CILy of Evcrclt emplayces havtng kno�vledpe a6outUi!s Inddent: <br /> _Fci�^f.����1.flar�� frlh/• .f�i.r/,�ei� ,i .�y,�r.t�.La_/_.L�rl�a�b�_t'��_W/�9/'•b/ <br /> � ���--lr�- pt4� � <br /> I4, Names, addresses and teiephone numbers of all IndNlduais not already IdenUlled In #12 and F33 above who have Imowledge <br /> regarding lhe Ilablllty Issucs Involvcd In lhls incidenl, or knowled9e of lfie Clalmant's irsultlng damages. Picase C:Qude a bdef <br /> dcsaiption as lo lhe naturc and extcnt of cach perwn's knovAedge. Attach additlonal sheets If ne:essa.ry. <br /> 15. Deurloe the cause of lhe InJury or damages. Euplaln Ihe e�eten[of property I�ss or medical, physical or menWl Injurles. Atlach <br /> addltlonal shects if necessary. <br /> ?�v t�ur�l n:a /�w r�r�wred_e.t�_d�iacE�d' , � �/o�N <br /> ----GS,�td�.hi�_�Gu�dingL��Q[c��� eDy�a�a..��_��ard.fe rools,l i,i.z�s��,c. <br /> dr��a, ' ��,_d�4w.p�mI,e.o-z`)•_-./4—�11f��a..,� u_�1��a�Ced_ <br /> S'e�J!_'�!( T� I�hL_!(�LY�.A.Y.IN'�A1Y 'C"�`a'r"s'If�___7�41•L�_Qr.d <br /> I - J <br /> — ' ILTL.C�tf_. �_ <br /> 1G.Has lhls Incldenf becn reported to law enforcement,safcry ar security personnelT tf so,when and to whom7 j <br /> y_.������..�,�rsf_Gr�,i,��'�Yy«��-l�j—�•'��-� <br /> 17.Names,addresses anA telephone numbe�s of trealin9 medlal pmvldcrs. 1lttadi wples of all medlcal reports and blllings. I <br /> — -- - - ------ -�2a,— -------- - --- --- — <br /> 18.Please atfadi Aoniments lhal suppoit the clalm's allegations. <br /> 19.I clalm damagrs(ram the Cty of Everett In tne sum of$�0], oz <br /> Thls dalm form must bc sfgncd by cill�er thc Galmant or an behalf of thc Clalman[by an attomeydmfztt who holdS a wntten powcr of <br /> attorney for the Clalmanl,or by an altomcy at latv adml[ted to pnUlre In the SWte of VJashln9ton, cr Dy a court-appro•�eA guardlan or <br /> � 9uardWn ad Illem. <br /> I declar�under penally of perJury under the laws of the SWIe of VJashinglon that tl��e foregoing Is lrue and couecL <br /> slg�ure di'Uaimane��l%� Date /'/3 places g ed (dty and state) <br /> Rov.07/09 <br /> I <br /> � <br />