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] t. if lhis dalm Involves a vehlde auldrn�Jwlllsion, provWe your vchldc Informalion:. <br />PIrMNa. Pfake l9nd:l lear <br />Orivcr'sNamc Dnlrri(Imnsch'o. YehldcOnnc.•(sJ(i/�AOeren[fmmdmrrJ <br />Ourxi�InsurarxnConquny PhnneNn. Po!lryNo. ^ <br />12. Plamcs, oddmsses anA telephone num�zrs of all persons InvoNed in or wilness to Ihis Inddenl, <br />13. Names, addresses ard telephone numhers of all Clry ut Everett employees havin9 Imowicdgo about lhls fncldenb <br />14, Rames, addresses anA letephone numbcrs of all Indlviduals rrot already IdenRflttl In Al2 and q13 a�ove wfui have knowMdge <br />rega�dln9 lhe Ilabil8y �ssues InvoWed In Uiis IndJent, or knowledge o� tha C7iimanl's rosultlnp damages, Pleasr. InduAe a b�ief <br />desalr,�ion n� lo thc naturc and extent uf cacfi ��erson'sluiowledge Altadi uddilluual shcets If irecess�iy. <br />15, De,aihe Ih� aiuse Of Ut� InJury nr damagw. &p1ai0 lhc e�lenl of prope�ty Io55 Or �ilCAlctl, physlral or menh� InJudes. Attach <br />addltlonal sheetslf neass�ry. <br />�.�w d ✓1 /)d. J � �2 9 // � ('Q 4FQ�D 'i/� �i��l✓L+7L L%✓t� Tb N�.�C/' <br />N �(fc —�4st:w�a-'r" '�orct�.���-C�i/+.fJ lC�rY{��_r,_ /�K. <br />� j7Ov/tep B4.r oF t-/���'` fi.v! �L✓�T•i" oN fq� ��po�?w�i <br />�s—..c�ni i �Glel 'l—.U-t�" r?efr_.ts.c�.-0`" CEr: (��.vG �taViJ ��via C�� <br />_��ti4.N�TT_ _F=LeeI`- �t�G�P f7_u2��iG T/l+�f iNe�p �r <br />t6. Ha5 thls InclAcnt been repoded m law enfartement, sefety or securlly perc�annel7 If so, when anJ rotdmm7 sn'� RZ�i}oc(C—D) <br />17. Nemes, add�essr.s and te�ephona numUers of UeaUng medlwl provldets. Allacl� coples of ali medipl repoits �ntl blllings. <br />18, Pleaso nttadi docmnents Ihat suppuit llie clalm'c allegpUons. <br />19. I dalm damapes Oorn Ihe Cily of Evcrclt In lhe sum uf $ 7~�,�.�� <br />lhls clalm farm must br. slgned by efthei t0e Galaiant nr on Ueheif of 1he Clalmant by an altumey-In-fttt v�ho hokls a wrilten powcr of <br />altomey for Iho f.loirnant, or Iry nn altomey at law admqled [o pndice In Um Sta1e oP Washington, or �y u rnud•approved 9uardlan or <br />9uardlan ad Iqeqt <br />I dalaic under nenalty nj�t�dury under lhu latvs of Ihc: Shla oF WasliingtOn lPal Ihe foregDlpp Is lrue and mrretL <br />Claintanl <br />Rav.07107 <br />