Laserfiche WebLink
Ll. if thts dakn Inwhes a vebkle aocidentKoWskn, provlde your vehkk b�fomatlon: •� <br />, � ' . qs.MMa . �Mbke M�d�l Hw <br />DiAeiYNsme 06AerrfkedeAb k�e0Ma7e(�[Mt1'uNNmthpnAM�r) . <br />OmrrS�tnsraanceLW�panY . � MareAb. f�r�'a � . ' <br />... ..---- -" ----..Wy----.��___•_"_____��.��._..-�--y-'��..��.�._M. <br />23. Names�addre�es and tdeplane numbas of all CRy of Eltiett irry�loyees havhq knowkdqe a6out Nds InddeyF. <br />14. Names,.bLdrL�es and telrylane rwmbers af all individuah not �k�asdy IdenUli� In M32 aM i�13 a6ae who twe knowledge <br />reyarding the IiS�fllly Issues Invdved In Ws Incldent, u Imowkdge cf the GWknant's rewMrg dama�s. Please inch�de a brief <br />desvlptlon as to tli! nature and ahnt of pch person's Wbwldk�e. Altath addltlonel SheMs M necessary. <br />15. DesQihe the wse d the inlutY ar damages. Fxplaln the edm[ of propMy bss or mediol, physical M mmtal InJuAes. Nfadf <br />addlttanal sheet It rKoessary. <br />S�w�R 3,9c,14.-fJP � i�A►��4G�rL O Ar�T t�ARX <br />16. Has thh Incident bem repartM ro �aw enfararnent, sNdy a searily personneR tf so, when and W whom7 <br />17. Nart�es, addresses and telephone mmbers d hea[Ing rtkdiwl providers. Attach copla d all medlal rcports and MWngs. <br />18. Pfease attach dacuneMs that wpportry�g�mY allegaHms. <br />. :�1 ^' <br />19. [ daim dameges hom the GN of EverelFll� mm of f Q. Z�� <br />This dalm lorm must be siyncd by either the Cialmark w on behaM d the CkYnant by an alborney-Mdad who holds a xrtiltm power of <br />attorney for the Qdman� a by an attaney at �+w admlGed to pradice In the Scate of Washing0on, or by a mutiapproved gua�Wan a <br />guxdNnadlRem. <br />2 declarc under penalty of perJury under Ihe laws oi tlx SWOe of Wasfiinglon tlut the foregdng B true and aorreR. <br />PI� <br />rtw. orroo <br />