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ll. 1� Uils clalm Involves a echldc a�tident/tollislon, p;ovide your vch!de in;mmr�Con: __ . <br />P!a!eNo. P"n4r hbd:;l Ica� ��, <br />CPirer:sName O:irci'slicenseA'o. ✓r1Jde.lY.�ner(sJ(ildiNercntliomdnvc�J � I <br />O.�neri /nsuianm Compa�y Phanc No. P�Giy!✓n. <br />i2. Names, addresses ari lclephonn numbers of all per,ons Involved In or wiln�s [o thls InddenC <br />! J. h!ames, addiesses and lelephone numbers of all Gty, f Evc�eti empinyees having knovActlge a5out this IndAc�P � <br />19. Names, addrr.�:es anA [eiephone nunibers of atl IndiviAuals not aircady identi'ied in It12 and �:13 above who have Fno�,vled9e <br />regarAing the Ilabiliry is;ues Involvrd In lhis inddcnt, or knov:lcd9e of the Uaimant's resultin9 damagcs. Plcas^ Inctude a brief <br />Cescnption as to lhe naWre and r�tent af each person's kne:��ledge. Altach adAitlonal sheets If necessaiy. <br />`� 15. Descn�e the cause o( lhe in;ury or dai.iages. Explaln the extent of property loss or medica!, PhYscal or mental Injuries. Attach <br />additional shec[s if ncccssary. „_ . _ , <br />] 6. Has this InUdent l�een reportc�l [o la�v enforcement, safely ur security personnel? If so, when and lo whom? <br />' ��� J <br />I7. Names, addresses and lclephnne num6crs of lrealin9 medical proviJcrs. Altach mples of all mediwl reports and blliin95. <br />1 H. Please alt�idi JnrumenL� thal support [hc clalm's atic9ations. f e�t. �'�Or ')dl�) ! i�v�� -- <br />�= �: r J <br />19. I d�inl d�mages (ront U7e Clly of Evciett In �he svm a' S .(./5�� �9^�('�j A(99Q- �i)(- ( <br />1 hl; dalm form mus[ 6e siyned by elther lhc Claimanl or on beha�f of lhc Cla�mant 6y an attomey-in-fact who holds a tivrittr.n powcr ci <br />a1!orney fur lh= Claimant, or by an atlurney at law : dmittcd to prar.tice in [he State af Washingtor, or by a court�approvcd quarAur <br />n�.�aidian ad litem. <br />: decla�_ under pen�lty o( perjury under thr, laws of Uie Slate of 1Nashington thal Uie fore9oin9 is Uue and correct. ! <br />i <br />� <br />���.',,;� �1��� 'V� �'?�" �`1' I S � �1 � � � v; �, 1� <br />-� \ - �`-t,_.�`---- -- ---- - - ..; 1�, ��vw_�. .J�:'�� <br />Signat�e of Claimant Date Place signed (dty and state) , <br />nev. mmP � <br />� <br />