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il, tf thls dofm InvoNes a vchlde aNdenV��llsion, pnrvlde yourvehlde Intormallon: <br />P/ah h'o. Fla.in Nodef Ytar <br />Onlzlsdan�e Onverl�llrnnsrh'o. ✓c!rlNeQrrneKs)(l/0'NcmntdomdrNrr) <br />Onruv'sMmranreCcmpany Phanello. Pa.�IryNo. <br />12. Names, addresses and telephonc nunt6ers of a'I persons tm�otved In or wltness to thls Incldent � <br />o ,:�dL.f��qnyF�n2J <br />� � <br />I�t�u ��nc(� Po . t'..i,��� . v tc - z<-�. S94Co �{_L� - 3 3 0• ��, � <br />13. Nam¢s, addresses and telephono numbers oF all Clty of E�emR employces having knowledgc abouc th's InddenC <br />14. Names, addresses and telephone numbcrs of all 1ndlvlduais not already Iden11P:J In C12 and k13 a6ovc who hava knowledge <br />regm�ding the Ilahillry Issues 6rvolved In lhls Inclden[, or knov+ledBc of the CIelmDnt's resultlnp demages, Plense fndudc a hdef <br />descdpGon as to the nelure end eMent ot each per;on's Nnovdedyc, Allach aGd'�lonz! sh:et5lf neces�ary. <br />I5. Descrlho the cause of Ihe In)ury or domages. Exptoln tha eatenl af property losv or medlcal, physlcal or mental �nJutles. Attach <br />addltlowi shmtr If neceseirv. <br />IG. Hns this Incident heen reporMd to law mfarcement, s�fety ar scaAry personneli If so, wheo ond to whmn7 <br />f�U <br />1'/. Names, nddresses and tctephonc nun•�Bers of ueat!np medlral provlders. AlW[h coples of all medlwl rcports and hllitngs, <br />f 0. Plense ottach dacumenLs that suppmt the tialm'a olle9ntlons, <br />�1— <br />t9, t clalm damapes fwm the dry of Everett In tha sum ot $ `� <br />Thts clalm form mus[ ho slqnetl by cllher tho Clalman[ or on Uchaif of the f.lalmant b�/ an alWrnoy�lndact who holds o wduon power af <br />altorncy for the Galmanl, ar by an altomey at law admilted lo piacllce In Ihe State oF lVashtn9ton, or hy a caurt-approved Ouardian or <br />pwrdlan ad Illem. <br />1 dttfaio urtler penairy of perJur r� ider thc taws of thc Stale of WashlnOtoo lhat tha foregoing Is true anE corrcct. <br />— �j`f.G�_i's __�-_zJt�z�11� , L�%•(�, <br />s �acUa�"r,-mi;d �---" - � Dato Place signed (clty and atato) <br />R�710B <br />