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11. IF thls �alm irnolves a vehlcle accidenV�oilicion, pruvide ynur vehidr informaliac �l '�—_ <br />P/rtr.il2 �4aAr. Fltx/^7 Icar <br />Nume <br />�/ � <br />lArnrrs/nsun. ncr Conp:iny Phane No. <br />12. Names, :iddrcsses and tr.tephanc nwnbc�s of aI! person; Involved in ur witness to this indtlent: . <br />�/!-v� c�f�3���u•.:✓ io„w �V. P�r�r_ •)2 r.:v�+r-c:�r`i' — <br />,yla y' ., r �S�G -- /2'.=d 2- --- — <br />13. Names, �ddressrs anu i<<epimne numhc�s oI'all City oF F.vcrelt emp�oycis havinp kno�viedge about Ltiis IncldenL <br />tA. IJames, addresscs and Ictephone numhers uf all Indivlduals not niready Idmtified In k12 and f113 �fwve who hcvo knu�vledge <br />regarding U�c Ilablllly Iszues 6rvuived in this Inr.idenl, or knnwled�o of Um Clalmant's rc;Wtinp damaars. Plcase Indvde a Urief <br />descripdon as to the nalure and cxicnt of each pnrson's kaow1��19c. AlWcii additlonal shcaCs If nacssary. <br />� / A� <br />I5. be,cdho U�o wusn of Ihe injwy ur tlanlages. 6epiain Ihe erlert of pioperty loss or tr.edic;il, physiwl or mental injuries. Allach <br />addilianal shecls if nr.ccccaiy. <br />IP��+, �FG G- ,'tl Fr�c���i-r.,°____ e_fT u¢-S� 'T/=r no_t O�� r.vM..c.�:-- <br />--1�'l�`"_ 5 R-n�i� i%critt�Nr'rv��L'v' . M,t_ w�t••5 /�c.�n�T1i•. 1)_ ij-s r v'_g!>2'2�U <br />� _ .. . - — -- = !i.wa*�o-_ C4vHt•�. �<, _ ,_ .. ��.Je ��-n ,, r_ �r .. RRr .e• r ... <br />%i/i4-Y_'�_S . __"'_—_ _ __ <br />1G. IW�, lhi; (niidenC licen repod�rf lu law enforccmenC, safr.ry or secutily prrsunncl7 If !:n, when and lo �vhnm7 � <br />A/ fi --- <br />17. Name�:, adJir_tties and Ieir.phone num�ce. oF t�ading medkal providets. Allach eoptr.s o( ail medlcul repods and hlllinps. <br />]0. Picase aUadi ducumenL•; IhaL suppmt the doim, nllegaUun.. <br />19.1d�tlmdama9csfromlheCllyufL'vcreltinUiesumuf�: �'I'�'�-��[) �NJpiGC-. c i (�o� ^�Ar�. ��^1�`���' <br />Ok1V/ - nOti i`%v� tN�-'�ui�c I,ttt� A�n^. ', {�l=F=�.M <br />'f hfs tlalm funn �nus[ Lc siqncd Ly e.iihcr thc Cl�dmanl nr on Lchall' uP ilm Claimant 6y an ntlurnuy-indacY vrhn hnlds n�vriticn pmvcr uf <br />;itlomr.y for Ihu Claimmt, or by an auorncy al lavi odmltteA lo praciler.ln lha Slite vt Washln9ton, or by a wwC-appro��ed 9uarAian or <br />9uardian ad litem. <br />t declorc undcr pr.nalry u�eqtny undcr Ihe I:�we of lhe Stalc of Vlashinnlnn Iha[ thc fum�ainp ts tnic and o�rrecl. <br />�� � �` G'JE�c�� !✓.b:.,,�f <br />���,�>:rt_, �-.,.._ r�r1��1�;- - <br />Signalur of Claim�nC Datu Place Rigned (ciry and stito) <br />❑ev.n7m�� <br />