Laserfiche WebLink
�— — — — — — ---�---- —i i <br /> � � <br /> ; <br /> v � <br /> ll.if thl.s cialm Involves a vehlde accldent/mlltslon,provtdr.your vehldc In(ormation:_� I <br /> R'a7c ho.�A13kc Plodr� Ycwr <br /> Owe/sNanre onverslla�nsrNe. Uch�PoU�r,rn(s)(i!d/Icre.vt/re.�ndriverJ <br /> Ouncr's Insm.>ncr.Compvry Phone!!a. Pdfry,VO. <br /> I, <br /> 12.Na�ses,adAresses and telephunc numbers of a11 perm/ns InooP�ed h�or w.itnes5 lcl lh{s Indd°nl�. <br /> �_l-=�J�/-_\� IfLLJ��.=��fUS\�C.i(.�(!1� _ Y �'� J'1I-�5 j' �)�� _ ' I. <br /> �se�lieL_�K�G✓`.._..`J'�P1�-�i'I-- �"l.'>e!�_t�t!< � � �� ���� I1 I <br /> — �— °— � — <br /> li Wames,atldres;es and Idepl�one numUersol all Clty of Evcrelt emp!ayees having line� � �_r abau[Ihls Inddent: ; <br /> �_—__—_-_- — . - —.___ _. ._ _ I II <br /> 14. T:ames, adAmsses and[elephune nUmbers o4 a11 IntlNldutl5 nol ;Irea[ty 1dcullOcd in 7tt2 unii lt13 nbove v:ho haue knorAeGge If <br /> re9aid�n9 tfic II�Slllty Issucs Invalv^d m thls h�ddent, or knavAcdgc of Ne Clalmont's rzsulting damagrs. Plc,se Indudc a oricF �i <br /> desctlption a;to Ihe nature and extent of each p�rsoii s kno:•Jed9e. AC acn addlUonal she�ts I�necessary. �� <br /> , __—____. j <br /> - I <br /> __ —.--- i <br /> I5. Ceticrihr. Ihe cause ol Ihe Inj�ry or damaye5. F.Hplaln Ihe extent af pmpetly I�ss or metlrcal, physlol or menfal InJutles. Altarh I I <br /> adAitioral shec[s if ncce��ry. . <br /> (l,^/'L%'l.s _�/�f-'���:�r�✓�J 4G/'�✓_ ,�> /_C/' �'w,l;•;f' .l.1..�.,.,'.,.« �i I <br /> •L _ I <br /> �� \ . . �� <br /> /�-=:l.V _C`=� llUS._ li.."✓/� i�i��)�1/^l1 -C�l:tirVi�'s!__ i <br /> �___. I <br /> -'--'_' _- —._'_' — I � <br /> "' � I <br /> 1G.Nas lhls Indden[hecn re{:arted to law cn(r.<cmcnt,sa(r.ry ar secudty personncl7 If so,when and to r�hom7 � <br /> - r��_� '_ __ " _""__'_"_ ' . <br /> 1/.n�am�s,addmsses and tMephone numbeis of treatlnn medlcal p�ovideis. Atladi co�les of a'�,I medlcat rePorts and hlfllrgs. ; '' <br /> i <br /> � ----- - --------- —�------ I <br /> - - -------- -----' - ....----�---- � <br /> IP.Pleuc altad�dacumcnL lhal5upporl U�c d�lm's aVc9allons. V'G I <br /> � � It9.I d,Im damo9es Irom Uic CIP�of f.vcrclt In thc sum of$_/..�Q,.__. <br /> Tln;clahn(orm m�st he:Apned by clther the Galmant or on belmlf of Ih�Ciaimanc by an attomey IndM tvho holJs a�vtl0.en pov;cr of � <br /> attomcv fcv thc Clahnunl,.r bp an otlomey at law adml¢cd 1n prazticc In thr.Statc of Woshlnnton,or by a courbaDProvcd 9uartlian or � <br /> guaidian ad hl�m. <br /> t dedam imdr.r penalry ot pei7ury unAer Ihc la�vs nf Ihr.Slate of VJnshln9lon tna[Ihe(orc9oing Is Inm and corrccl. <br /> // � <br /> �/ � ,^.� <br /> ��/� ��J�i,� �--- ��5 c��� L� v r�:�:�� l,i� <br /> Siynah�ro oF�ini3nt��/ �----- DSI� � Plnce sipne�(city anU st�ate) I <br /> I <br /> eirv.urui� ,�i`;_�y- �!(J� � �i <br /> ��. �'54�:41.e�y�� ����� <br /> �''i� .�✓�:( � r� /�' <br /> i <br />