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i1. If Ih4•dalm imotres a veldcle acddent/collislon,provide your vehide Informatlon: __._ <br /> . lv�tcA'o. /dakc F}odrl Ytar <br /> ' Y�� _ <br /> Dib�er's Nanr� Oiiver's Llccnse A'a �eh.Y1e Oirnci(5)(Ud�%lrrmf fiom Advcr) <br /> Orrnri's/nsutan:e Com�y Fhone h'a. oa%¢y Nn. i <br /> 12. Mames,addresses and lelephonc numbcrs of all persons Involved In or wltncss to thls Incident: I <br /> l:� �;G,� a/�6�, r����x .J/��rr.hr • �-,,.4 ,,,i;..�� r- �,,::,/�.� I <br /> 13.Nantes,adAresses and tclephone numbers of all Clty of Evuctt employecs having knov�ledge alwul thls Incidenb <br /> —.�iv��l'G,�,�f+r �,G S�•t _�� /•7.-u.l_�c••.S�is,r;,�u.f... <br /> _'_— _. .—._. I <br /> 14. Names, addresses and telephone nembers of ail individuals not alreaJy IdenUficd In 7t12 and N13 :.�ove whu have knowledge <br /> rc9arAln9 [he Ilablllty Issuez involved In this Incident, o: kr,owledge of thc ClaimanCs resWUng damap¢s. Pleaze indude a hdef <br /> descdpUon as to the nalure and extent of each person's knowicd9e. At4th add�tional sheeL d necessary, <br /> 15. Descrlbe the cause o(the Injury or damages. Explaln the entent of property loss or medlcal, physlcal ur mental Injurles. Altarh <br /> additional sheets If necessary. <br /> . 5�.���.�i i.i��S!_ !_+I /ou�rn �Ai` .^/rr�;�_ !••..-.y.�-Il o..._ r.,.../ _ <br /> i <br /> G,,,��_i�`/ :✓,(/• .(! . <br /> IG. Has thls Intldent been re arted to Iaw enforcement; safety or secudry per;onnel7 If sn,when and to whom? <br /> --_._ ._ -��__ _ __.______._ — � <br /> V.Names,addresses and telephone num6ers ol treal�np medical providers. Attath coples of all meA'cal iepoits and hillin9s. � <br /> ` ----- ---- ' <br /> — — -------- --------^— I <br /> f 0.Please altach JocumenLs tha[support the clalm's allegatlons. I <br /> 19. 1 dalm daina9es Irom[he Ciry of Evu�[t In Ilie sum of$_._fj�rlc!��f ���3 ���"�� <br /> 7his clalm form must be si9ned by eilher llie Clalmant or on hehalf of the Claimant by an attomey-Indact who hotds a wii4en pm��er n! <br /> atmrney lor die Claimant,or by an atcomey at law admitted to praGicc In U�e State nf VJashington,or by a murt-,pproved guard�an or <br /> 9uardlan ad Iltem. I <br /> f declare Under penalty o(perjury under Ihr.la�es of the Slale ol PJxhington thal lhe fore906�g is true and correU. <br /> !"� .lt • .--�'�'_— � '2�`__/.f �t�-�>��/U�. <br /> S�i n5kureol'Claimant ate Placesigne (cityandstate) <br /> Rev�07109 <br /> i <br /> i <br /> i <br />