Laserfiche WebLink
11. If lhis dalm Involves .� vehlde accldenU�ollision, providr. your veh!de InfoimaUon: _-__ __. -.----. -- <br />IMatr. Nn. Flakc bbJel Ycei <br />Orinv'sNan:r. .._. _- Otla'r's(ltrnsrh'o. -. . -----�eMdcOunci(s)(ild,rmm�ffiomddvcr) --.-.. <br />Uwne/slnsaranmCompany —�'—����� �l�o�'=Na. <br />12. Nam�s, addresses anA lelephonc numbers of all perxins Involved In or wltness [o lhis IncldenL• <br />�.cw �. l;✓��J%.N_3GS'�a�?n�,��t�:�rr.,_r��A_38��J,_1��-�95�-_>7S/ <br />'�� � i 7 rz1 � t c �.�+ di= I'i8N — <br />Lf/1lPJ���2c C6y�L.; rN iiL��,�_i_._ S.�.� _- 3�l �ZS_.� '- <br />�-�Ca2D5� �//IP,!?l •- 1?Ar'I ��U/'�/lr`/_ Sc�1�1�1;� %�20/3y/+Ti'�i;i:_%i�,_%2L;-_�S2,c;��-%6 JE lf.�'1- <br />r7D/fnr.�o5 w�- <br />13. IJames, addresses and telephone numbers of all City o( [verelt employces having knovdcAgc ahou[ tlds incldmt � <br />11. Namrs, addresses and lelephone numhers o( ail individuals nol already IAcrtifcA In X12 and i113 atwvc who have knowledge <br />re9ardin� the Iiabiiity fssves involved in tMs incident, or knoHledge of lhe ClaimacPs re.ultin9 Jamages. Plcase include a 6rtef <br />description as to Uie naWre anA udent o( each person s kncv�ledge. Attach addilion�t sheeLc I( necessary. <br />I5. Describe [he cause of lhe InJury or damages. Explaln the extent of property lus: or medical, physical ar menbl In)uries. AtWch <br />additlonal shecLs If necessary. <br />_��j��C-=�T1L3� t-1�l�-li%��-�_�_ _. <br />16. Has Ihis incident been mported to latv enforcement, safety or se .udty personnd7 If so, when and to r+hom? <br />. _,.IL: __ _. __. ... _ .. <br />17. Names, aJdresses ind telepiione numbers of lreatin9 medical pwWders. Attach copies of ell meAical rep.�rts ond blllings. <br />--- �il/r� <br />i f3. Plcase atlach donunenL that suppnrt th^ elaim's allc9ations. <br />e <br />19. I daim Aamages Irom the City of Everetl In the sum of p_J �"� �-' �� <br />7hls daim form must be si9nr.J 6y either the Clahnant or on bchalf cf thc Clalmant by an altomcy�lmfact who holds a wdllen powcr of <br />attomey for Ih^_ Clalmant, or by an iltomcy �+l law admilled to prr.r.U�e In lhc State o( Washin9ton, or hy a coud-approv�d guardian or <br />guardian aA litem. <br />i dedarc imAe p� n� Ity of pcijury under [he laws of the Slate of Washlnq[on [hat ll�e foir.goin9ls lrue and mrrttt. <br />, <br />ls t�_ �� �/G � ,3__ /'�Jd`i�r`q, Gr/r'�- <br />Signa e f C a hiant �' oa.e Piace signed (city and state) <br />Pev.07109 <br />�" -_,� <br />� / , i <br />�� <br />� � `, <br />