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<br /> I1.If[h's clalm Im�a!ves a vehide a�ciCenqcclhsion, provl�le yuur vehlde Informatlon: _ �
<br /> PlefeNo, Glakc A,'odd Yrar
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<br /> C:n,r ll�rr,^ ,;l � D:i t,�s[IcrnseNu �eh/deOwnc�(sJ(ildi/fi•�enttromddvcr)
<br /> _���Y.�vl'l� :���''l`6Lli' ;t�1 !r�� .�, U__—
<br /> C.ineh/nswaxeCompany Fhon�lJo. VaGryM1'o. � .�_f ��e'Le�
<br /> l?. IJames,addresses ard telephone numcers of zll pe�som involved In or v:ltness lo thls inciGenh � I�,
<br /> n IL, �� �, �l � � �"
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<br /> 13.'iVam�s,ad �e ��.s"an telcphone num�*:r� . •;;�City of F.verett empioyees having knovAcdge ahou[thls InddenC
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<br /> !4. Plancs, addres:ss and tclephone numbers of all individuals not alreaAy identi.`ied in J:12 and kl3 above who have knowiedge
<br /> rc;ard!ng the liability Isues InvolvcA in Ihls iricident, or kncvd=d9e of the ClaimanPs resWting damages. Please Indude a hrieF �
<br /> ues��iption as to lh naW�e and ent of ea�n person's kno� Ied9e. Atlach additlonal sheetr If nece sary .�
<br /> '��. ���''+��-i C�- _'/IUL,�� � l��tLC�C�e ��_ 1 � �i.. ,�.1� i` �� ��� � �
<br /> J� L-l/ �C u �Lt� � ��1. 1/ �l.f ���.1�/J
<br /> j- �...7� �iC� !� 7 C���.'.�� :<�U/��.'.t �.,i 1.�� ,� Y� .r L% rt'�_�'�� ,{�L< ) �.�.c.��j,—�.�;7` %'l�; �e,� I
<br /> ��t !l 1„ 1' i �(.'Gh�.6� ` �„�, C./ UC'���', �i ��(;� � � �, �� � � �,
<br /> � 1� `v � i Ol . ) r �� � �a .�,.I r«<<� • Ce _.��,
<br /> � � c�` c��i�i r.� 7�� �.. .i./ ,< � r ,o�.-.r r �- ,,.� _,_�
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<br /> 15. De cribe the�c�us� o,the in�ury or damages. Fzplalh lhe exten[o(proper�+�ss of'medical,�hysFca�o�mP ita inji rlc.� ttach�� ll tip� li
<br /> addi6owl=_heel,If necessary. � � %�i �� ��
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<br /> �i l c:;�r �; `_ �:i'`.,C���-i���,��>r1J ZL-,�t'�.l% �c,�c���/ � _�,��;�. �
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<br /> 16.�lo,this Incid-n[baen reportedv la /e ifprcement,mrety or securiry persocnel% If so,v�hen and to whom7 I
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<br /> 1?. Names,addre;ses and lelephone numbers of li�ly��il pmviders. Attadi copleti of all mcdiral repo�t5 antl billings. I
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<br /> Itl. P�easc.ltaeh documcnts thaf support lhr.elaan's allcyatinns. � � , /� 'i , I
<br /> / [ �1 �� , �_ f:ll<F, ..<-Llc.;-�:��4� �
<br /> 19. I �Iaimdama9sfromthef�tyoff:vcrettlnUiesumof3_•( D !%e' �� -�.^ �'� �' � �''��� l � I
<br /> vi �� I.x.P �-
<br /> Ihls cialm form musi bc si,ned by ciUier the GalmanC or on behalf of the ClalmanL bylan attorncy�lniact r�ho holds a wriltcn power of i
<br /> attomcy�or ihe Claimant,or by an allmnr�a[law adrnitted lo pradice In the Stafe of R�ashin9ton,or by a murt-approved 9cardian or
<br /> guardian ad Ii[em. � � I
<br /> I Aeclarc und� enalty�o. �^,yury fi er�he laws of Ihe Stale of Washin9ron that the foregoin9 is huc anA mrred. i
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<br /> Signa[ur oe F Claimant �� � �%� �� D� � Place signed (city and state) � j
<br /> kn�.o7iay I
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