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I1. ll thi; �I�im Involvcs a vc�'�;'�� �re�Cr �IlioPir.ion, C<<�v�,',c your vdii:lr.� h�`.crmabr.nt f,, f•;, . /9eSr F.Wf_�l Ihv <br />Ornrr'sh'anre � — �"—���li�+"sUcenseNo. _�'--' �eA'd:�On�uq'sJ(/Aitierc,a7fm.md/fvcvJ "-- <br />Unn✓'slneuran:e[GnrP�"y .. `�—_._—.Flrnneh'o. PafryNO.—._— <br />12. tlames, addresses and telephune numhcrs of . II pe�sons Invoh•ed In or a�itness to this Inddent: <br />���Lia:�li �L �L_e�=�— a<-i�.�a�c_s� E�E,c�1�S'J_�Y��-7o/� <br />- �%-�1�_y���C- - -�������,��� __r��� ��� ��s--�-�'�y <br />1?. I+ame;, addresses and Ir.!ephone numbers of ell Ciq� o! Fverclt empinyees having kno��deA9c ahou[ thls Inc.denh <br />_�<�B1<��+�oti-k.s'-.�IS��cJL__S.`,��.��_�,�'u��� �',�sr.�.r�_�,3�. <br />i4. Names, aAAresses anA telephone nu:nbers of a!I Individuals not ulrcady Idenlificd In Al2 and SI3 . hovz vhio h�ve kno�Nlcd9c <br />re9aiding ihc liibility iswes IovoWed In ihls Incldcnt, or knuwl�dpe of Ihe UalmanCs resultmg damages. Piwse. induCr. a Lucf <br />dic�criptiuu as lo lhe nature antl evtrnt of each person's kno•�dee!ge Attach aAditional sheets If neccssary. <br />IS. Describe the cause o( the Injury or damages. EKplaln lhe �alent uf prop�•rty bss oi medi:al, physl:al or menlal InJurie;. A[tach <br />adAlGonal sheeL If necessar��. <br />�4�1���'� llaor��Sc;./11c��� i1��'��1;'_��_1�'�� c E ��r�-- <br />F�_/./ +���H s�r��v��u� -��'A���_A.�_L���t__�_o��2r��— <br />C��l.�a ��_o f1�� �fs=� F�'t��ci� p on/_ ��3n/�3. �- Hq✓�_c,���Kc�. <br />C_L-r.��_�_��� �ar,_.:�Na-ct�S-`�-��o-b�j� �`-'�r.f' e�y ..� or n�tn,e -LrQ�Lrs <br />fi'a_ ��a_�`':%s� �i�l _/.-/aak&-- — ��li�,--G_. _�en� . _ <br />1li. Ha�, �hl; inrident I:cen repn�tcd to law cn(GtCr.mcnt, 5� leiy m;rartily perso7mr17 I� WIIPII df1A It115'I10017 <br />/V O _' — —.—__. __. <br />t7. tl,,mes, addresses anA telephone numbers of lienling medical piovldeis. Attach coplcs of all mrAiml repo�ts and blilings. <br />I A. Fl�.ae �dtach AncumenL• that suppoic Uie dalm's alkgal!ons. �1 �. �� . <br />. / � <br />19. I clalrn damagcs fiom Uie Clty ot Gverett In the sum of S_3 J�?=,rC..!^f 1^C`\ � �t (� t. ("�L <br />I I� : ciaim fmm inust he signed �y clthei lhe daimant or on bclialf of Uic Ualinanl Uy an attmney-in-fact who hnlds a w�inc:i power of <br />.-�Itnincy fm lhe Galinanl, of by ��� attorney a[ la•H �dmi0.cJ lo ptaclicc In lhc St2te of Weshfng:an, or by a�ourt-app; uveJ 9u.mLnn or <br />quvdlan ad IllCm. <br />I� �dam und��^_n�dty of perjury unCer Ihe laws of Ilie State o�Vasliln9ton lh�t the foregolriy I; true. anC cotrecc. <br />, %���-T,/�'%lIi1�1�i ��%/����q (�n�-�,{t'd' `�!/.d�� �-�-- L�L� ��.��llS_�'� '"/��rl <br />��i--+— �—�; -/ r\ pate' Pl�signed(cltyands[ate)(/ <br />r Signamre aFClaimant � J <br />Huv.07109 <br />