2414 OAKES AVE 2022-05-03 - Laserfiche WebLink

11.If this claim involves a vehicle accident/collision,provide your vehide Information: "" bf- Plate No. Make Model Year Drivers Name Driver's license No. Vehicle Owner(s)(If different from driver) Owner's Insurance Company Phone No. Policy No. • 12.Names,addresses and telephone numbers of all persons Involved in or witness to this incident: • 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this incident: doe c*i e1 B1vf411J' boo tom. 14. Names, addresses and telephone numbers of all individuals not already identified in #12 and #13 above who have knowledge regarding the liability Issues Involved In this incident, or knowledge of the Claimant's resulting damages. Please include a brief dion as to the nature and extent of each person's knowledge. Attach additional sheets if necessary. descrip , (1-�S PL1,1PIN Elk4 PL D`4& c . /Nv 414 b&C� r • • 6-71() 2, 1 t,t_.. * rrlurt-fz. (nod s i5. Describe the cause of the injury or damages. Explain the extent of property loss or medical, physical or mental Injuries. Attach additional sheets If necessary. itrr 7 ?i\ib tiG-,u ET lea vee: M/J sekor64r l -vff4 . �`ltry 6L lam- C` .1 6Nrm Th LA-w� (U 10-61�� - )N i'i15ji�. I 1J A 0 rim 6Arr�-6A-1 d S A 13 ircM-gb u`p tam 4) r- i z V err aJ -7-14 B NI• reVeNTUf3�L.L-V (.LQ Cv//s l 7-Li L •V-a-rod k4 u(fir1\i L EXPE- lCi '1 16. Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? C4rki Pt3LIc 1/46_ - s 63�� 17.Name s, `addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. 18.Please attach documents that support the claim's allegations. . 19.I claim damages from the City of Everett in the sum of$ g q©. This claim form must be signed by either the Claimant or on behalf of the Claimant by an attorney-in-fact who holds a written power of attorney for the Claimant,or by an attorney at law admitted to practice in the State of Washington,or by a court-approved guardian or guardian ad litem. I decl e under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. � - n14,3 W*- Signature of Claimant Date Place signed(city and state) Rev.07109 G7/1(