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S3. f( this daim tnvolves a vehide aaident(mllision, provide your vehlde Infortnation: _�� � — <br />� � � - - Pfa�e h'o: Muke � PIoOeI )'ear <br />Ll-iir/s <br />Company <br />(i/diNemnt /rt�m d,�ivcr) — <br />PolrcyNo. <br />t2. Names, addresses and tctephone numbers of all persons Invoived In or witness lo lhls inddent: <br />_ �Lnr� <br />�-/LS • �(2� • SUc� % <br />L.n.,�_ yz-s'• �x� 7 - ��oZ <br />13. Names, addresses and tclephonc numbcrs of all Gly of Evcrelt employees havina knor:ledge a6ouc thls fnddent: <br />14. Names, addresses and telephonc numbers o( ail Individuals not already Identified in N12 and #l3 above who have knowledge <br />r�arding Ihe liablliry issues involved In lhls Indden!, ar knnwiedgc of Uie Claimant's resulling damages. Please Indude a brief <br />descdptlon as to Uie nature and uAent of each person's knowledge. Attach additional sheeL if necessary. <br />I5. Descrihe the cause of lhe injury or damages. Explain the e�Rent o( pioperty lo� r medical, physcal or mental injuries. Attach <br />additional shceLs If necessary. <br />L <br />i3/1`��.tvl(•;,J � �1��'(7J7"G!; %lI'�dtfUfi <br />::�� i,�,:G _ d.i..ia.ii�+/��I� i�R7�vt�(�[_ /ZJ <br />�%fi`�6(�TL%— (i� /�i)T]=_.✓/7/�b /YiUt. � /.S`.>/.!'G 5 _.. <br />16. Has [his incidcnt been rcported to law enforcement, safety or searity person el� IPso, when znd lo whomt <br />1;'�,�'!_ !7� n[-I C i�.k)lll� � JU lU� > il: /'19. --- <br />17. Names, addresses and letephone numbers o( treatlnq.medlcai pmeiders. Attach mpies of all medical repoNs and blllin9s. <br />lU. Please allach documents Iha[ supPort the dafm's allegattons. <br />19. I dalm damages (rom Ihc Ciry of Everett in 11ie sum of $_ ��� ��� <br />Thls daim form must be signed by ellhcr Uie Claimanl or on behalf of thc Claiman[ by an attomey-ImWR who holds a written power of <br />attorney for the Claimant, or by an attomey at law admltted to pacUce In the State of Washin9ton, ur by a court-approved 7uaidian or <br />guardlan ad Iltem. � <br />I declam under penalty of perjury under lhe Iaws of the SWte of Washin9lon lt�a[ lhe foreqoing is true and corred <br />of Clalmant <br />Rov. OT109 <br />oate <br />signed (city and state) <br />� <br />, � <br />� � ` /) <br />i\\ j' � , <br />