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ll.If ihis dalm Involves a vehldc aaldenVcollislon,prov�de yaur vehlde InformaCon: ���e Na. f1uAn MaJel Ycar <br /> piPoe�'s6Smre OR'sv'sdmnsef�o. VeA�deOwnei(sJ(!/A�NemnNronrdm�mJ <br /> Owre/slnsuranmComparry PhnneNa. � Po'iry4'¢ <br /> 12.Names,addresses and telephone numbers of all persons Involved In or�Ntness to this Inddent: <br /> Sir�-�_ 5�,,�,� 4as-35o� 3Sia —_-- <br /> IHII Is� �+ F,�� �^'q 48�1 -.- <br /> 13.Names,addre>ses and[elephone numbers of all CIN of Evcrelt employees havin9 knov+ledge abou[Ihis InddenL <br /> .Q��yS•�p�ah�i vas —a�7__Qq�_ <br /> T <br /> l4. Wames, oddresses and telephone numbers uf ail InJivlduals not already Identlfled In J112 and 1173 .bove who have kno}vled9e <br /> regarding lhe Ilabllity Issues In'+olved In lhL• Inr.ident, or knot5ledge ot lhe Clahnanl's resultlng damages. Please Indude a hdef <br /> Ae;cdpUon as to lhe naWre anA extent oF each person's F:nowiedge. Attach addltlonal sheels If necessary. <br /> 15. Descr@e tlie cause of lhe InJury or damages. Explaln tlie extent oF property loss or medlcal, physlcal or mental InJude:. Altach <br /> adJlUonal sheeLs I(necessary. <br /> 0.it- ln.��l'��� c t,.Y_5 'Suhm.S_c�,tL_�nd <- �tf__�ia� � <br /> ��i5_._I�{x—_�-`In+ rvid Y1EA?��� I;�F 1.�z �IQ l_s. '�l�ean <br /> a;yb.};�. �+ 3���-� hot ��.� x� gf�h�c�p��-l.�r�i' <br /> �-�d�a�iod—.lo �ccd' s�+P_y��.�m_Ps�m_N (�'-p°�—�--���-- <br /> –k�a��cs��tS—�lad1� rcc� hdcX�Q�c.�e.��C vnr,.�'�6Z <br /> 16.Has lhfs Inddent been reported lo law cn(o¢ement,sa(ely or secudly personneR If so,when and[o whom? <br /> 17.�ames,addresses and telephone mimbers o(irealing meJical provlders. Attach coples of all meJlcal reports and blllin9s. <br /> 10.Plea.e al+a�h documenls Uiat support lhe dalni s allc9atlons. <br /> 19.I clalm damaqes Gom Ihe Clty of Everct[In the swn of$_�� a �� •�• <br /> lhls clalm form mast he slgned by ellher the Clalinant or on behclf of the Clalmant hy an apomey-Imfact who holds a wdlten power of <br /> allomey for lhe Qalmant,or by an attomey at law admltted lo practlm In lhe Slale of Washln9ton,ur 6y a court-appioved guardian or <br /> guardlan ad lilcir,. <br /> 1 dCdarp;Unrcr penally of per�ury w�Aer Ihe laws of Ihe Statc ot N'ashing[on lhat thc forcgoing:s lrue and correct. <br /> ��/ 4-�3_ �,,��I wl� <br /> Si naturo of Clatmant Dato Place si ned(city and sWte) <br /> Rov.07109 <br /> 7� ' K '/ <br /> O� <br /> _ � <br /> ��c ��� <br />