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, , <br /> t1.If thls da�m Invotves a veti!cte acddentJcolllsion,provlde your vehide InformaUon:__._ . <br /> � � � - PNfrP.a. �.'a.fr Plodr/ Yesr <br /> Oib�+r�Namu Odvei'sLlnnmNo. Ueh.'tleQ:rncr(sJ(ildl/(emVlrumdd�2�J <br /> _._ i <br /> Onnr�klnrurdna Cnmpany !'hanc No. FNiy flo. i <br /> i <br /> I7.Names,addmsses and te:ephone numbers o'all persons Invaived in or witncis tu U�Is InddcnL• <br /> - — — --��— ---- —� ----- I <br /> _— _._ __ — _. .. i <br /> —._'— � <br /> 13.Names,addresses and tclephone num6en of aL Gry of Nerclt emptoyers having kncwledge about this Inddent: I <br /> _-��.,v���c>�!����nw���sc�a�� ..o�`����_�r LA_.2-.�,�•(,c7 � <br /> _�:�1� "[�-e�t�--L�_�--`'s:.�=.�i!�_�{c�2�-_C�ip'u��..v . <br /> V <br /> 15. tlames, aAdreas^s and te!ephone numbcrs of all Ir�ilviduals mt aheady Identified In fl12 and x13 abuvc «4v have kno•N;edge <br /> regxrding thc Ilahlllty Issues lovolved In thts Incldent, or knowledgc of lhe Clalma,iCs ra�lUng damag<s. Please Indude a brlef <br /> uesaiptlon as to tlie nature and ex[en[cf each persan's 4:nowledge. ABach add�llonal sh?els If ne[essiry. ` I <br /> � <br /> _� � 1 � ' _ a ��-�. �. �. -co��:;_:���F N.��cc�:, <br /> ���._/��w,,���.,.� 1.�.--. � `�--;;- —�.:,---�-j�1-_ � <br /> __Y_Y_ k"i�i�` __�--���]=L11Y1�(:1_��(� ��'!y[� �^�� �i = i <br /> ��.F2—�.��-l-iaL.�G r�t- G��.c�..?Lr.1J�..) —_ � <br /> I5. Descnhe lhe cause o`the inJury or damages. Explaln lhe ex;ent of propeity loss or medlcal, phys!wl ur mentel Injuri^s. Attach <br /> addiUonal sheets If nececwry. I n r1 <br /> �] �L.1.u...l. ^��1.f�LCZr�� 1f:J 6.L�;p`�i`L�Q�G�(� 34�`�[�r <br /> _ C15C1`.�.1-v\�� ' _r�µ(� �.�1 ���.•—LUA•`�—�t��. n� �� 5----LC...V-C�/�(� .`•�-.ra9-ELrY,,, <br /> '�iP1���.Cp.ltl._—l..'�iti_L-V��+CL`7c`..LklcL��7.S;(c'x� C-a�{a-1�=1���c4�X.�+�--�C¢_J�— i <br /> �`.�L'L?l_.���V(. tW_c1�—�[-Ci.Y�Q�LLLI'=1.Mr�`�[...._�>�•-�?G}.ILY�I.:�_'_._ I <br /> 16.Has Ihls Inctdent heen mporteA to law enforcemene,safely or,ecmity personnel7 !f so,�vhen and eo whom7 li <br /> i <br /> .___—�ro �. ( �.�o_�_���.(��n�������L.�-1n.2�,-�s ---- <br /> � <br /> V.�lam^s,adAresses aitd telephone numbers of Irealln9 meAkal piovideis. Allach roplesof atl ineAlcal repods and blilings, i <br /> ---C 1/�� — -- -- �I <br /> Id.Please attach iiocwnenLc Uiat support ihe clalm's allegallons. I <br /> 19.!daiin damages from Ihc Uty af f.verzlt In Ihe swn of i�2���=ta�.�i�.• I <br /> 'Ihls dalm form must he slgned by elthcr the Clalmant or on hchalf of Ihe Clalmant bV an attomcy-Imfad who ImIJs a wd�ten power of <br /> altorney for the Clatmanl,or by an altoiney a[law a;ImitRd to practi:e In lhe State nf N'a;hlnylon,or by a courl•apD�o��1 9uardian or <br /> guarAian ad Iltem. � <br /> I declare unAer penalry of per�ury under lhe laws of Ihe Sla[c of Washingtmi diat Uie forcgoing Is tiue and correct. <br /> � �� � ��{���.� � --�— <br /> L L��l-4_.0 Q �~�_ _ _��' w�'��l ������� ���.1___—_._ <br /> Signaturo of Claimant �-� Uate Place s�gned (city and sta[e) <br /> Itov.07iO3 <br />