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11.1f ihls claim Involees a vehlde acciden4��llslan,provide your vehide Informatlon:_ <br /> P/ateNa n/aFr 4kde/ {'nv <br /> Onver'sM1'ame � Ontrrs[/rensaKo. VehMebwn!r(sJ(�fAi/hrcnt/runCn:n) <br /> [kine✓slnsuroaro[1m,vnY � Y/rorteho. PakyA'a . —.... <br /> 12.Names,addre.sses anA telephonc num6ers of all persons involved In or wilness tu thts Incldent: <br /> '�� _t;r� ��wl & r-.�..�_ I�.rs:,,, - R�S.�Fa.,,« --- -- <br /> � <br /> ______ —..� i <br /> 13.Names,addresses xnd tr.lephone dumhers aF all qry of Everelt empinyr.cs ha•�ing knowledge aboW Ihis Incldent: I <br /> Ci�L- 1A.6�1;t-. Oit a.ltl I <br /> —�— ------- --'-----__.— i <br /> IM1. tdames, addressrs and tMephone numher of all 6�dlvldunls not alrcady IAr.nUCrd in N12 anJ A13 abuve who have knowledqe �� <br /> reyarding the 1ia61ilty Issves InvolveA In thl, InNdent, ar knuwled�c af lhc dalmant's resulting dama9cs. Please intlud= a 6rlef �, <br /> descrlptlon as to the nalure nnd e■ten[oF each persan's knowledge. A11ach addRlonal shech I(necessary. I <br /> �eil- Sterk�.nC�1f.�dtya�,c.� ID031 ft't�r.� Sf N !1 - 6.,faaN G.A9 f8o11 <br /> ��Z''__`�S(o--�1.'15.' 1�111 Rl�alt ��t>..nrne.... e2�'�!t e_c�]Crv'�� V.1n-ste.t '� <br /> IVL�4k�'Z1wie�. �]'�Z L". 141�r.,�, Var�a_�?1 5.•���- A- EveaN �1'��820\ -353iJ5g�(o <br /> I5. Desctlhe lhe cause of lhe InJury or damnges. Fxplaln Ihe exten[of property lass or medfcal, physical or menlal InJuries. Altach <br /> addltional sheels if necessary. ' I <br /> � �..•.-. �rt.r.� i v�� =•r.v�r.�r'� �itt.Hrpiv 4'WI•� ��c�C(Cerp i.tp,l�/( �oE •%/.s <br /> --T— � � <br /> WUL'tr �'�wr aG� �N �n r� Q - ' �_��c.�S_o�bLtii4.1�C�.�_..CJ:o+K .�=C�c<c:R ta{� <br /> 1 <br /> _(f.nil 1f<c � . Q �.Il e-x7sle�.,YttJncI�43 �row�. MY�Ip=Mma..'t E+.a.Ca�r�-f�,la.�sS� <br /> _�Sesi*c�_WCF,\.�toc��pe. 5ur�oc_�t+�-���LIl'I �Yx4r4.at is �lt� ���a•�-x...t�1.Cln..Wcll <br /> �a W�.�\ .r�u�....k��Q 1 - Ili,n_ 1V41L7�_l .��aL(Krb.r lu. T•..•.Eme..�. Wt.s cQ..r+«ye L bayu.�.e feft.t�� <br /> V I ! <br /> (6.Has lhls Incldent 6c n reported to law en(orcement,safely or secutlry persCnnelt If so,When and lo whom7--� <br /> ��- -- -' - �---- ---- '_ '- <br /> ll.Names,addreues and lelephone num6ers of trcatin9 medltal provtders. Attath copies of all medical re0mis and biltlnps. <br /> tFl.Plcase attach dc�umei��s lhat support lhe claiin's allegaUons. ^ ` <br /> 19.Idalindama9e,GomlheQryofEvcrettlnlhesumof;��cP:SS__<-�� �3��������V <br /> Thls daim form must be signed by cilhM lhe Clalmanl or on hehalf of the Qaimanl by an atlomey-0mfact who holds a wdttcn power of <br /> attomey for lhe Oalmant,or by an attomey at law admitted to praclice In the SWte of W.shinglai,or hy a coud�appiovecl yuanlian or <br /> guardian adlilcm. <br /> !deda!e u pc I FpC y under the laxs of Ihe Stalc of WashlnAron lhat the forc9olnp Is tmc and mrrttL �I <br /> '�-- ------� ----•�� 5-7_v13 �,,,�,��� u.1U`ti I <br /> (gna eofClaimant Da[e Placesigned(cltyandsate) <br /> aov. 9 <br /> II <br /> /�-� <br /> �a � <br /> � <br />