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i <br /> 11.I(thls clalr Invotves a vehlcle actlden�colllslon,provlde your veldc7e Informallon: <br /> P/ak Na. Nake Mdc/ Yarr <br /> lLi�erYll.vne Omxr's[/ce�mlh, Uch.YICO�Me�(s)(dd/lr.pnl/ramC�M1trJ <br /> 0�,ncr's/iuuar�c Company PAone A'a. Pa',ty Na � <br /> ll.Names,addresses and[e!ephonc numbers of ali persons Imnlved In or wltness to thls Incidenh � <br /> �lp,,,� f�t�iw=���-• L�:as=��rv -s3-�y <br /> 73.Names,addresses and tclephone numbe�s of ail dry of EYerelt employecs having kna�vled9e about thls InddenL• <br /> _ �Jh�i c�__lnk,r�:�� ��..,�-,r�'rn P.-.�-- . � <br /> 19. Nam^s, addresses ond te!ephone numbers of all indlviduals not alrcady IdenUFled In #12 and Nl3 abovc who have knowlcdge <br /> rcgorEir,g lhe Ifahtllry Issucs Invotved In this Inc'dent, or knowledge of thc qalmanPs resulling damages. Pleue Indudc a hrlef � <br /> Aesnlptlon as to the naWre and e�lent ot rarh pr.r.ron's knowled9e Altach addlllonal sheeLs If necessary. ' <br /> I5.Dcxd6e!he cause of the Injury or damagea F.plaln lhe eKten[of property Ioss a tm:dlral, physlcel or mental InJurles. Attzch <br /> additlanal sheeL If necessary. <br /> �P, . »� LVCt�'�O��l l C�l c�sp��nQ,__ ��7rx.S4��' <br /> -- i�te . i'�,��. �5 h,�e ����c r,l.c.�k- — <br /> 4as thls lnddent heen mported lo law enforcement,sMery or securiry personnelT if so,when and to whom? <br /> 17.Names,addreaes and telephnne numberx N treating mcAlcal provlders. Attanc�oples of atl medl4il m(aits and blllings. <br /> I8.V'uise ullach dacwnenls ihal suppnrUhe clalm's alle9allons. '— <br /> 19.I dalm damages Oom Ihe Ciry of E¢erett In thc sum ot$ r�� � <br /> Thls Natm form must 6c stgned by elther thc Galmant or on behaff of Ihe Clalmant by an alromcy-In-faR�vho ho!As a wrltten po«tr ol <br /> attomcy for lhc ClNmarl,or by an atlorney a[lavr admltMd to practltc In Ihe State ot N'ashington,or by a murt•approved guaNlan or <br /> guartllan ad Iltem. <br /> I decla u der penalty of ehLry under tlic lav� �(lhe State of Washlnqton that Ihe forcc�otng Is true and mrtcd. <br /> -.u-- l C�J�.� � l'"�= �� —(n _ -J�i � CJe c tf , c,���Q <br /> �I�-- <br /> Signature of Clalmmit Da[e Place signed(cltyand sta[e) <br /> flnv.07f09 <br /> �I� <br /> r <br />