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i <br /> 11.if thls dalm involves a veh�de acdJenC/mllislan,pmvide your vehlcle informaGon� � .. .. _ . . _.. ' I <br /> MaM h'o. M1lake A'odd "�Ycar <br /> I <br /> On:rrs Narnc - �� � � � Avrei's[irento No. ✓cd�dc Onaci(s)lrfd;Krn�nt lrom dd�rr) <br /> O�e�Cr3lnsvrarxCComhvn�• . FhoqCA'o. VNryA'o. " , <br /> 12.Names,addrcsses and telephonc,numbers of ail persons Invch•ed In or�vienrss lo this Incitlent: i <br /> J[Z� GIZ7J 1 �r� /k// �.�r.l�r:� /�-(.Gr"C727LrT� �/�S�-�''G�7��6 Ld'� <br /> GL ( ��L9Vr,�i77�L5` s/k-rJ��� _ �-.9/!':' ���� I <br /> /� _ ST f�� Cs��l'/� S=�-1l,Lr' <br /> 13.Names,a�tldres�ses a'ni telephone numbcrs o(all Gly of Evere;t eqrnploycc,havin9 knmvtedgc aLout th�s Indden:: <br /> �1��2�1�Y`��h/�'_--`�'_ S ���(�n�";%,�UL'(Z <br /> . _ <br /> - �E1�� �'��-�� _ <br /> 14. ?James, adAresses any telephone num6ers of all Individuals no[ aiready ider.tificd In #12 and #13 ah�ve who have knowiMge � <br /> iegarding lhe liabllity issu^_s Invulved in thls Incident, or knov:icd9e c( the Cla�mant's resuitin9 damages. Please in:luCe a brief <br /> de.sclr p��on��":u to the wture and e�tert nf cach per��}'�s know!edge. Attach addltional sheets if necessary. � � <br /> �/(G�"U�_�t�'�l/' i'-�.���(.� �-{,t; L�12%7�-�� YZj' z�`�r.S Lo3'la`_'r;�,/�v,i� <br /> 15. D=zcri6e lhe cause of the InJury er damages. Explaln the c�tent of property loss or mMical, physiu�l or mental Injurie5. Altach <br /> addiUonal sheets It necessary. <br /> {�JP,.I�> . UreRe1� � �i�'t�X.`� i�h��=��a.�Jl(c�1''� /N'a__ia!�y1'IL�L7- <br /> f3�� f,'�.'1'1 �" LP_�A�//I/liG �? L. r�' � S' lt 7 1�( vUYi-Tl.`//�_ ' <br /> !� �i,L�7l,��/5-,(�.�VisfZ1� � � ��1��('f�"I�TJ V 7 ,U',��� ![�.(�` <br /> c . ,.; . �r_ Lf?1:�[' �__...�'�.—{,(S�]!_.`>L��f�c� �� 9FIr� i C���f� nn•J/1, (S <br /> -- - �761-�l� • S 9�-'��.e5�(�� A''- ��.sr.z.v��,�rt,���"�r_�=ev rSir�i22 r'sse--- <br /> —�.-- <br /> 1G.Has this inciJent been reportecf lo law enforcement,saiety or secudry personnel7 If so,when and to whom7 <br /> .��-�' --�__..�._ . —.. __-'____._._.�.�._..- . <br /> 17.Names,addresses and tdephonc num6e�s af treallrg mcArcai providcrs. Attach roples of all mcdical reports and billings. � <br /> _ -._.�- ----� T� . i <br /> 18.Plcase altarh document:th��t�vpport thc clalni s allcgatlons. <br /> /nI � <br /> 19.I dalm damages Trom Uic Gly of Evcrett In lhe sum of f_�_L`JL___�.• ' <br /> 7his daim form must be signed by cithcr lhc flaimant or on hchalf of llie Clalman[by an attomey-in-fad v:ho holds a wntten povrer of <br /> attorney kr Ihc ClalnianC,or by an a.tomey al law admittcJ to praAlce in Ihc SLrie of\�Vashington,or Iry a murt-approvN guardian or <br /> guardlan ad litem. <br /> I declare undcr p Iry of perJw vnde� laws of the SWte of Washi ton that the forcgoing is truc ard corred. <br /> _ � - � ^_ �� t � -��J���s/�` i <br /> •z5ignature of Clafmant � Dat Place signed(ci and state) <br /> Rav.07109 <br />