Laserfiche WebLink
� L].Iftfilsdr.Iminvoh�e:avehldeaxidenVc•�" ,'-rvl:!cyourvehldehdurmation:_______- <br />j� . _ . . . ._ .. fYafc,S'v: � Al�le � l4oAc1 le�r <br />Odvv'sM1:�mr � Dnreh[Icrss_h'o. � �chldc0«ne�(s)(IId!/etcaf/mmnn:�r) <br />O�.rr.✓slnsvrarmCanpmv J— PAoneNo. <br />1 Z F:ames, addre;:r_. and lelephmie numbe�s af <br />, � <br />C�_a..va,rti.,'�—'�'z;.Ic��_v��l � <br />,�._,n. r_•�.�,. _ �i.r� <br />Invohmd In or v;llness lo [hIs Inddcnl: <br />��a�� s�-l�=����� <br />�.5._ �`�°L-��l`l <br />13. IJxnes, addres:^s and tclep'i�ne numhers oF all Ciry of Eberett employces havin9 knc�.v!edgr, aboul Uds IncidenL' <br />_�v��LJo rlLS' s ai'c�ln __ _ �ia,� < i� ��. <br />i`l: _— ��'-�- �` :?57-sS00 ur � ° _ '1`3%_c�3''3�2 <br />14 Wames, e.ddresse; , nd tcicphone numixrs of all Indivldua�s noC already IdenllCr.d In ;f12 and �13 ahove who have knoa7ed,qe <br />re;ardln� Ihc IIa6iGry Is:ucs Invoived In U�I; In:lden[, or F:nowiedge cf thc CfalmanPs icsulUna damagc:. Please indude a 6rief <br />dr.xdptio�i as lo We nature and eMent ef cadi pe ,on's kno�:�ed�e. Atlach adtlltlon�:� sheeL; If nen:ssary. <br />- 15. DesalCe the eawe of the InJury or damages. EKplaln the e�Rrnt of propeity loss or medlcal, physlcal or men�l InJunes. Attach <br />� addlUonal:heclsifnecessary. � <br />�cc r�,"tin�., ���a v f� _ 5(',ri,e.cc•� .y�F� �,'��%G�•� � �nD t� <br />n I.1 �,���•-F(� �- r�.,�,..�J:,'in� ��21.�-�5�.��-- ' s�}-• �-l� y�r �MOv'P <br />i.:� �l'. I. I V V I.T u' L ' - . �. � �i • ; �... . . . . �_..�_ <br />� <br />_�J= (.an;��L'• <<��Srl.!4d P�.�.L vLJ_e���� '� �-/o«^� �nti/_�s�_ ��CD�cL��i��— <br />c�,yLL-�!��✓,y' 7 Ur ,�IOY`P 0'cYt^�"'�I—�._z1�ti�i- t-i3S i` :i�F��,..__j-L��.l"S'_, <br />15. Has Uds Inddent �cen rcported �o lavi enfoitement, safety or semiity personncli If so, �vhen and lo Khcm7 <br />--�� - -------�--- �------- "_. <br />:��. Names, adArc:� �s and lelephone numbers of Imalln9 med;cal provldeis. Altach coples af oil m>_dl4il reD��s aiul blltlngs, <br />lU. P�^aie ath:h doNumnL•' that support the cl,�lm':� ullegalimi;. <br />19. I da!m daina9es fmm Ihc City af Lverelt In Ihe eum <br />This dalrn foim must be signed by etlhcr lhc Ci�iinnnt or on 6chulf o! Uic Clalmant by an altu, ncy-Indac} who hol�k a wdtten powcr o( <br />allomey for Ihe Qalmar.t, or by an attomey at law aAmllled lo pradlce In the Sta0.: o('Nastdn�ton, or Ly a caurt-app�uved r,cardlan or <br />guaNl, n ad Iltem. � <br />I dedam under prualty of perJury under Iha lav:s cf the SWte o(N'ashln9tcn that the forcga!n9 L Gue und mirec[. <br />� L� �,, ,-,� � `� > �3 ���«���� w� <br />S�gnatur�laimant � �Dato �Placosfgned(dtyands[a[e) <br />. <br />Hav.01703 <br />