Laserfiche WebLink
li.lt chis dalm Involves a vchidc acc,denV�a�llslon,provldc yaur vchldc Information: __—_ - _— <br /> MaleNo. M,akr, hL:dd YCar <br /> Onirr'sNnme � Diiver�L/renseho. 14hrde0ivnei(sJ(i/d!f(rrtnt/iomdrfrerJ <br /> Owner37nsmanre Com{vny Phonr h'a. Pu:r.ry M1'o. <br /> 12.Nam:s,addresscs and tclephonc numbers of all persons Involved In or tvl[ness to lhis Inddenh <br /> Y01 l�Ol1_TVNI \H I �/ il 'V�Pi.�ll�i IZ�'Z�O'�J77 - <br /> }=e�in �p�u���ctinr{ '3So� SI '� �r. NC �,Mti�,,svill.e I�/�//f�LZo 7.af�-Z`(�- � ) <br /> -- � <br /> 13.Names,addresses and lelephune numbers af all Cty of EvercU emp!oyees havin9 knowledge about this Inddent: I t <br /> _.�V{^ <br /> i�i. Names, addresses and [elephone numhers of all Indlvlduals not alrcady ideneified in k12 and n13 a6ove viho have knmvledyc <br /> regarding the liabitity Issues Invol��ed In this Incidenl, ar knov+iedgc of lhc ClalmanCs resultln9 damages. Vtease InduCe a bdef I <br /> descr.ption as to the nalure and extent of each person's knowledge. AUadi addillonal sheeLs If necessary. <br /> N�/� <br /> 1;. Descdhe lhe cause af the In�my or dama9es. Explaln lhe eztent of p�eperty lass or medical, phy9cal or menWl InJuries. Attach <br /> addiUonal sheets If nece aiy. �/y; <br /> `���_ � �(�`ii'�(1`.-- <br /> __ _ I <br /> IG.Has lhis Inddent becn reporled to la�v enforcement,sofety or secutlty personnel7 If sv,tehen and to whom7 <br /> Nl� __ <br /> 17.Narnes,addresses and telephone numhers of treating medical providers. Altach coples of all medical repods and blllings. <br /> N�� - -- <br /> t H.Please altafi doaments Uiat suppml We clalni s.I�e9aUons. <br /> l9. i clalm damagcs from the Gry of Fvcrett In Ihe sum ef�,�_•u n . <br /> Thi;dalm(orm must 6c s�9ned hy cithcr thr.Clalmant or nn h;holl of the Clalman[by an attomcy-In-fad�ti�ho holAs a wdtten powcr ot <br /> �dtorn^y lur lhe Claimant,ur by an altomey at law aJmi4eJ W pracUee in lhe Slale of lNashinglon,or by.court-appmvcd 9uardian or <br /> p�iardian ud blem. <br /> [dcdare undcr penairy o�perjmy under thc lav�s of the Statc of Washington that tlie foregoing is Irue antl rnrred. <br /> �'n���� � 9 t���3 _Mav_�s�;�_��f� <br /> signatura of Clalmant Date Plac signed (city and statej <br /> - Hov.07109 ' <br />