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11.If tlds clalm Invu'vcs a vehkic a¢Ident/co0lslon,provlde yourvchldc IMc,matlon: <br /> MafcNo. Meke /lodel Ycvr <br /> OrAer4Nanrc GivetYlhmreM1b. ✓cAk/eArncv(r)(NdiL'�rthand�rrJ <br /> Oimn'slnnnanre Co�,my PM1one No. Ax4ry No. <br /> 12.Names,addmsses and hlephone numbers of all p^-rsuns I�wNed In or wkness lo thls Inddent: � <br /> 13.Names,addresses and tclephone numbers of all(]ly of Fveretl emybyces havirg kncrMedge about thG InddenC � <br /> i4. Names,addresses and tekphone numEcis oF atl Indivtduals na[already bleMifed In k22 and k13 above who f�ve knowledge <br /> regarding the I!a611Ry Issues Involved In this Incldenl, or knowMdge of lhe ClalmanPs ��sulting damages. Please Include a Wlef <br /> deuriptbn as to Ihe naNre and eztent of earh person's know'.eelge. Attach additlarel sheets If necesary. <br /> - 15.Dexrlbe lhe cause of tfie In)ury o�dama9as. Euplaln Ihe extent of��ro�erty Ioss�or�medlral,physlcal or mentel InJuries. Attach <br /> additlonal shects H ncc�ssary, <br /> 1G.f las Ihls Inddent 6em reparted ro law en(orcement,safery or secudry peisonnet7 If so,when anJ lo whom� <br /> 17.Names,addresses and Mlephone numbers of liealiny medical provHkrs. Altach coples of ail me0lcal rcpods a�619Ings. <br /> . I <br /> 18.I9ease atWch Aocurtents thal suppod[he clalm's allegaUons. <br /> 19.t dalm dama9es from the City of Everett In the sum oF 3, t+_G� n/e 1_YYd7q'�'� <br /> This dalm fom�musl I�e signed by ellher the Cl�imant or on behalt M the paln�ant by an attomey-Indazt whu hoMs a wtltten power of <br /> aUorney far the CI�Irtunt,nr by an alromcy ot law admltted to practice In Nie Sta[e o(Wasl�ington,or by a mut•appraved guardian or <br /> guatdlan ad Illem. <br /> I deciaze under penalty of perJury under the laws of Ihe Stale of Wazhington that the foregoing Is Irue and curted. <br /> ����e �' /'.��:���P �-iy- �3 <br /> Signa ureo Gaimant ` Date Piacesignad (cityandstate) <br /> Rov.07fOB <br /> �•_ <br /> .�� J'` <br /> I <br /> i <br />