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11.If this daim Involves a vehicle acddenf/mllisipn,proviqe yaur vehfcle�nformatlon:_. /V I,is. . _ _ . ....
<br /> qate NaT Maks . . M�cfN � -...-Yaif�
<br /> . . .�—.----.-r.. .. _ .. . . . . ..�.� �.
<br /> 'DiM�'sName bdver'stirerueNa YrtiticOnncr(s)(1(d1,'ereaffromOrhe�-)
<br /> ..Oi+ner'slnsvranceComGHny � � A5oneNo: � � �A:h'ryNo.. . ... . .
<br />', 13,Names,addmsses and tclephonc numbcrs of all persons Invo�ved in or witness to this inddem: �
<br /> G��.�� ����� i-Y P;�l`, �_ ��r�.r - s,lQ. ,,�s�� -r�,,�,c��,�,��
<br /> a� �2�iaoi� �l� oo P�, � 2 _Tc,�o���
<br /> _.1�C 3�� Aa, �s�! C,�t,, �G�f_.l���U. .� 2 �lEc. vi�,��'� �
<br /> 13.Names,eddresses xnd tekphone numbers of a!I City of Everett employes having knowtedge ahout this IncldenL• ��
<br /> ,�1��h,�-w t�r� , _ _�.
<br /> 19. Names, addresses and tclephone numbers af all individuals not alreaay Idenlifed In #12 and �li almve who have knoNledge
<br /> regarding the ilablllry issues mvolved In this Inddent, or knowledge of the CI�ImanPs resultlng damages. Please Include a hricf
<br /> descripttnn as to the n�tum and extent of each person's knowledga Attath additicnal sheets If nccessary.
<br /> � _..._. . . _ _ _ _
<br /> 15:Dewibc the causc of thc infury or damages. Explaln the extent of pv{mrty Ioss or medical,physial or men41 Injuries. Attach
<br /> addftlonal sheets if necesury.
<br /> .. A���. ����6 c� $�:2S�1_� d�f � .,� 5�-�rn� P.�1�n�- -�Y�e 1a���e�' .
<br /> /1-, .' �C1-.n �.ivSE �.I�c\r .�.�4\. S�.nq�.n_� �0.�e�✓ 4�i �f�, ci�✓r�,�ale.. � .
<br /> /.tnc� oiP�6f�� u\nnir. o�k- o Wa . ,i (-Lt,rv cY� �.la nL
<br /> �--�.+, ., . �a:_Y��4. 3 I�rar �,S 1�,
<br /> - - - �a V,_ ' 1a�„ii '
<br /> i
<br /> , l U
<br /> 16.Has this Incident been reported to law enFarcement,satery oF securiry personnel7 If so,when arul to whomi
<br /> , ,�u.b�, c ��yks �.� , r��l�,d:�k.-.,-G.u.,�,.(a"-�
<br /> 17.Names,addre;ses and Iclephonc numbcrs af lreatln9 mediral provlders. Attach ropies of all medicil mpoits and blilings.� ;
<br /> . � �. ... . . . . . � i
<br /> d8.Please altach documents tha[support lhe daim's allegaUans.
<br /> 19.I c�alm damages from Ihc City of Evcrelt in thc sum oF g l X� .��u . n �,�• �l S 1,1'n -�
<br /> Thls daim form must 6e si9ned by elther Ihe Claimant or an behalf of the Clalmant by an allorneyimfact who holds a wriHen po�Hcr of
<br /> attomey(or U�e tlalmant,or by an attomey a[law admifted to pradicc In the Stale of Washington,or by a muK-approved guatdian or
<br /> guardlan ad litem. �
<br /> 1 dedare under penalty oF per�ury under the laws ef the State of Washington that ffic(aregoing is tme and cormc[. i
<br /> C�'1 3 � G '. ,�,. �yy � �J\,.^1__
<br /> . ,���xr�n x..a j
<br /> Signat re f Claimant Date •lace signed city and state)
<br /> Rov.A710
<br /> ` ��
<br /> �c���;:
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