|
: . 1 1 � `. . ' : �
<br /> 11.If this dalm Invaives�vehldc atciden�colqslon;pruvide,yourvehi,cle Infotma[ton:._..-.. . -. �.. ...., . _. ..,.. _ � _=; - �� I
<br /> � � �laM�b . Hake Mod I 'Yca�� �
<br /> _ . -,�_ - --�-.._— :� .
<br /> �Cn�rrs,Narjjc. .....---....... . ... -',.. . . bnleiSl7rnrse�Mu.� 1' id'eb�ner(s)'pfd,Re,�eirtfmmdtArrJ :
<br /> _. .. _�.....i--�. . :,..__ _ .. ._ ...._ .......__ ,,,_.
<br /> �O:mcr'slAsvrancrRyrp3ny MoneNa; � . .Po1ryAG.;�. ..'� . . .
<br /> 13,Names,addmsses and[Glephonc numbcrs of�all�erson;fnvvlved In ar�Nmess to thls Inddent: . � �
<br /> S�lon�o,� �'� m �485-7�01-3'7�3 TEw.4w'i'
<br /> Ph+9 _�rev'Ic(.c. � yd3'-a94-'YatfS. T .
<br /> _�_. _ .. ._ _ ,
<br /> _ ,. _ .,..____.�.,.______
<br /> � . __. _ . ___ .. _.
<br /> 13.NamcS,addrcsses�nd teiephone numbea of�all CSty of F.vcrett employecs havin9 knowledge a6out ths incidenFi � 1
<br /> _ ��vjc1_vni `{' f_P�,�• S�c�.io,r 1_`v�qinlce� �'V.t.IK.��. clkl;c'.W��r .- ;
<br /> _ Y�s�a���?.- �s�r�3 _ �., _
<br /> _-.= _ _ . ..: - _--...�, ;
<br /> 14. Names, addresses and telcp;,onc numbcrs of all Indivlduals not Slready iden6ticd Ir #12 anA kY3 Sbove�vho have knowledyc � ..
<br /> mgartfing thc liatiflity L•sucs invoWcd in thls Incldent, or knowicdgc of Ihe qalmant's resultlng damages. Please Indude a 6fkF
<br /> de5ulptlon as toYhe n3[um and e�eYent o(each pe{snn's Rnowled9e. Attach addi6onal sheets if necessary. �
<br /> _t3r�RRy 7'c-rRzdc - ,�z. �„s�� �.,r��s � 36v�5'Sb•BS94 ;
<br /> . .�__-... .. _ . ..._ ._..... .
<br /> �.<fG�a_„�riLKSon) `AL Gusrb�+*f Gonfrac�loK ' . . -., �:
<br /> _f ._ .. ... . _.. .. � .. .. . .. . _._ _
<br /> Ti�n Eri�lu�n�_ .�i L tu�awu- tenin�derf ,� _
<br /> 15::Oesaibe[he tause of thc InJury ar damages. Expialn:the exlent of propetty loss or mediwi,physial or mentai Injurie.s.;AttSch '
<br /> . addRional sheets iF�necessary. r f � .
<br /> �e+���9� !>>9CGC.�P CI lJ�IfW j�. .'��� �,qse r�-�t f. i�'i� a' , i
<br /> fiw i c�... Firs fi.. �l a�r3 . � 9'!S /�,.—_ . . .,.. ._ _ _ _ ..
<br /> � �
<br /> �.�....v..... . . ...... ... '.. n... . . . . ... _._.. . .T ... - .. ,' .
<br /> . .. . . . .. . ....... ,
<br /> . . . �-..�.... _. ..�...._„....�,,,.�^l;t_y�.... .
<br /> iG.Has tliis InddenC�been reportcd ro law enforc�nent,safety or secudty personneli [f,o,when aiid to whom�
<br /> , ,._._.,,. ...:....y.�.. �
<br /> .._ . . . . ._ . �.. .. . . .. . .. .._.
<br /> �
<br /> 17.Names,addre:ses.and telephone numbers of treating medlcal provlder,. AtG�ckcopies of ali medical repods and GIII(ngs�
<br /> ..... ---- .. ..,.. . . . . . .__,h..Y" . . - . - ---'° .
<br /> . V._.�.. ..V.. _�
<br /> ... . .. .. ., _... I
<br /> ' - - . .. . ..._ ___ .. _ _ . _. .., :
<br /> � ... _. . .:. _.., ._. , . .... .........�.,.. .
<br /> -. . ... . .. ..... . .. . ..._ __ . ,
<br /> 1F3.�lease�"hch documenLs lhat support the ciaim'salleeJaUons. �4 '�p� � � � � -
<br /> 79. [daim damages 1'rom.the Clty pf Everett in thc sum oF;.y�. �,y� � ` � ~/ '�
<br /> '<'G�-{---.�:
<br /> 7hls dalm(orm must be sl9ned by�ellher the Qaimant or an behalf of the Glaimant by vt attomey-itrfaGw�ho holds a wrilten Fnwer of �
<br /> allo�ney(q7 the Cldlman[,o�by an attarney.at(aw admitted to prnctice in the State of Washinglon,or try a murt-approveH guaNian oi � � �
<br /> guardi,an ad Iltem. ,
<br /> 1 declare y der penalty of perjury under the laws of the 51ate of 1Vashington that the foregoing Is.lrue and correcC.
<br /> / ,Gl.�i�'�- �._f�.`/ � ���_GLJ
<br /> �SignaturA of Clai nt � � � Date Place slgned(city apd sWte)
<br /> Rov.O7IOB .
<br /> . �
<br /> � 5
<br />
|