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11. If thls clalm InvoNes a vehiUe BcddentJmlllslon, provide your vehicle informatlon: _ <br />P/aR 1Jo. Make Flode/ Year <br />[yiverY fJame OnYcr's (Imnu Nn. �eh/de Owncr(s)Qld?cra�f Irom d�rJ <br />OKmerYlnsurancr.'ompany PhoneNo. R>/icyNa. <br />72. Names, addmsses and teiephone numbers of all persons involved In orwitncss!o!his inddent: <br />13. Names, addre� an�dj telephone �numj6rr� of aIlq City rof Everelt employers h ving kInowiedge a6cu[ this <br />Fu1�Qi L�(�MT � YrAl��ri �rJhf�lCS ov� SP,.f) �dhbP[" �.�-��� <br />14. Names, addresses and [elephone numbers of a�l fndtviduals not already identified in #12 and t113 above who ham knowledge <br />regarding the liabllity Issues fnvolved in this inciden[, or knowledge of the qaimant's rcsuRing damages. Pleasc Indude a bNef <br />desalpUon as to the nature aad eMent of ead� person's knowledgc. Attach additional sheeis if necessary. � <br />15. Describe the cause of the InJury or damages. Fxplain Uie exteot of prop:rly loss or medloi, physcal or mental In}urles. Attach <br />16. Has this incident been re{ <br />No <br />17. Names, addresses and tclephone num6ers of heating mediw� providers. Altach rnples of all mallcal rcpoHs and 6111higs. <br />18. Please attach dacuments that support the daim's allega[ions. e <br />19. I claim Aamages from the City of Everett In the sum of �'"�� E��rWII��LL'A, <br />Th(s daim form must hr. slgned by elther lhe Claimant or on 6ehalf of lhe Claimant by an altomey-In4act who holds a wiilten power of <br />aKomey (or the Clalmant, or by an attoraey at law admftted to prac[ice in Nie State of Washinglan, or by a mmt-approved guardlan ar <br />guardian ad litem. , <br />I declare under penatty of pet�ury under the laws of the State of Washinglon that the foregoing Is true and mrrect. <br />Sig�ature of <br />Rev. 07109 <br />Piaoe slgned (city and state) <br />