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]1.If Ildc dalm Mvoives a vetJde accldenVmlHslon,provide your vchlNe NformaUon: _ <br /> MtMAh Make FWCtI 1'ur <br /> f.,i�r�t Nanm OrlvnYlkenm No. lMNcklaMn(s)(1/dNlrrcnf/rtun dnlri) <br /> bvnerY;ttnvancrlivrW�Y lYroneNo. �,yy�y. '— <br /> 12.Names,�fdJr ses n id hiep6one numbcrs of all pmm�s In/vob�cd In or wimcss to thls IrcidenL• �^���/` <br /> ! _j,�/� LY/✓f?<,� —g[^--- �' �Z.r�e�(A 'CTYI� <br /> ---'J-�J-�SL�4� � _-.—_ /i <br /> 13.Names,adtlaKses anA teleptrone mm�Ucrs ot all C�ry ol EVerett�snNln�ecs Iwving knowledgc abou[IMslncidmt: <br /> ��� ��1� �� -� <br /> 14. Names, addmsses aM tekD�nc numbcrs of all IndlvlddaG not ah«dy IdenUlleJ In N72 nM p13 atrove who have knowledpe <br /> re9ardirg lhe IIablFty Issv�. Involved In lhis Inddent, a M�owi:dn,e oi :hc dairttimCs rrsulthg dama9e;. Mcase includc a 6ricf <br /> descdptlon as[o lhe nalure and cricnt al each peaan's knnwkdpa �.tto�,�+�ddlUonal sheels If necessaq•. <br /> 15.DesaWe lhe tau5e af lhe InJury or damages. ExpWln U�e eMen[a(property loss or medcal,phystral or mental In�rles. Attach I <br /> addltlopal sheels If necessary. � <br /> �u.���5—�/,�.�.Z.o.� X Z _-_- <br /> t ,Gta� ✓- a�✓ /�� 41,-r ,- <br /> �-.�.-c•—).y-�-'��- r� i -e�.e,-�L�u��P—S' <br /> ��� � A�l�'"�o_ ¢� e.,GL�.� X'is,n�_ — <br /> 1G.Has 1-�h�s hT�tl�deirt Uecn r�ated lo law enfmc nt,safely m securily Versonne'7 If so,wnen and to whoat `— <br /> 17.Namcs,adAresses and tckDhonc numbcrs of U�vting mcdlcat;roNAers. Atlach coples of all mediwl report�and bllMngs. <br /> I8.Please attach docmnents lhal svppat Ihe da'm's aiegatlw�s. ` <br /> 19,1 claim dart��s from ihe Ory of L�rereK In lhe sum of s �U �"�!"'`�' ���� <br /> ThIs claim form mu:t be slpned by cllhtt lhe Gaimant or on bchall of lhe Claimant by an allorneyin�fact who MIQs a wAtlen powcr of <br /> attomeylor the flalmant,or hy an dtorneY nt Ww admlttefl lo praUlcC In tlie State of Washln9tnn,or by a cour4apprwed 9uarman or <br /> guardWn ad tltem. <br /> T ettlarc undcr penalry of perJury under tlu�avrs of Il�c SIMc ef VJashington lhr.l lhe fnrec�aing Is truc and cortca. <br /> �� A /` � 5_- GJit, <br /> 9 gnature af Clalmant D te � Placa slpned dty and state) <br /> R�v.07/09 9� <br /> /V �f <br /> �I� <br />