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i <br /> f l.If thls claim Involve:a vchlde accident/co!Ilslon,prm�IJe your vehl:le Infomiatlon:.__.__. ._ _.__ I <br /> CIJfeNM1 ldJt�` p1oJPl >itrr I <br /> p'At+iSNeo'c—�_ /Ahri'S(kinnrNo. . . ..VrliYkOnrrri(J(ild;%lrtt�nNim�ddNrJ -'-�'— <br /> __"'_`_ '_""_ ___""'"__—'_"'"_ ___'_._..__._"___ <br /> Mmer's/roinr�K«limyi+��• l7rrmeAL N.CryN�. <br /> f2.Nnmes,nddresus and[elephone numhers of nll persons Invalved In ar wiMcss to Ihl.IndAcnk <br /> .l'a�1 ����, t�� iso i rHcli;r�_.�,�,-��-��-..M _ aa.,-�z,-•r�i�i �- - I <br /> S41�Irs1J.�y.er__ 15ti�1'�c�C.�_d,�,_('�ys,t«— -y��_��=3 i a � � <br /> � <br /> 13.Nar�r„a:ldresses anC tcicphone numbers of ail Clry ef Ev<rett cmployc�s h,ving knowlr�gc al�out IIJz Intldent: I <br /> _ I <br /> '_' "_. ___—'_"_'_"_" __'_'___""____'_ _—____'___"_'_"_'_______ I <br /> Iq, Names, addresscs aud telrnhan_ numhcrs o(all ladlvidua!: not already IEenUOed In 012 xnd e13 abore who have 4nowleA{�e . <br /> �egmd!ng lhe I!aL!lity hsucs Invotvcd In Ihls Inddrnl, or Ano�vltdqe of the ClalmanFs rcsulHng dunaget. Plrnse Inciu;ic a hlef �, <br /> descdptlon ns lo lhe nalure aml e.lenl of cach pe;son:knowledgc. Atla:h oddR�cnal sheels If necessa�y. <br /> '_'__' ..__._.�_ � ____'__ --_.___.__.'___ _ � <br /> —._ _."' —__'_' — I <br /> _'—___`_'__—" "_'.. "_'. _� ' _.—__' _'.__ — I <br /> 15. �escdbe flie cause of the InJury or damagc:. Explaln the ulrnt o(property los:ar medical, physlwl or mmtal InJutics. Ftln:h � <br /> addlUonal shcets IF nccessary. <br /> 1'�nllY}1fll'�C�'.l:'_"1.�J�'�(�/i��.�r�"1.�,J�S:J.d`Ii4tiL4�'�=-��'��r�_j�l_44.lt�C. !N'!=�_�J__ I <br /> IcuS�d�V_k1�.1G�'Yie��:.11]?1��.���.DG{i.1� 0�� u. .�'1���' "_ <br /> —!4 j__'_ '_ _ I <br /> '__ _' ' _ _"__' i <br /> 13(oc.le. Wr�i.1�. ��� 1_'s1141�� �c� I C�'�_�/'aiae�.u-�u;,t«n�i luin 1.-- <br /> �, -� 1-,---- f �---y- I <br /> i�l�bu���u�c�ai c. i}._t+. . e�l -¢r �.0 '� St.l cno1:_ • � Il : a_•���r���:rie <br /> 5111__._TT_�_.1_ J^_1�__�1.�"' ' (_— c�. I <br /> 16.Hus lhL-InclJenl 6ecn reportM Po la�r en`orcemeot.solety or security personnd? 11 so,�ehm and to whom? <br /> 17.Nanus,addresses nnd telephane numbers of lreating medicel provldas. Attach coples oF xll medkal report�and blllingz. <br /> — _"_. _. ._ _ _._ —_— —_ -. i <br /> i <br /> _____'—_'_"'__—_—.—_- --'—_.._'.________...__"—__"—_— � <br /> 10.�Icacc atlazli AxumenL-Ihet:uppnd Ihe<laini a ellegallo��s. <br /> 19.f clalm damages from Ihe fdy al Everctt In lhe sunt of 5_+D.r,e_e�r ttYlr��+�ec�.. <br /> Thls dalm form musl he signed by eRh<r Ihe Claimant or m�Lrhalf ol thc Uahnanl lry an altmney-Imlacl who M�ds o wdllen powcr of <br /> allornr,y(or Ihc CWlmant,or by an altmney al la�v aJndtt��1 tu pmcucc In lhe SWce al�vazMno:on,or 6y e<ourtappmvcd gwrdlan or <br /> 9uardWn ad Ilt<m. <br /> 1 Acda�c/u�q crpewlty of�rciJury imdcr Ihc laws of Ihe Stale ot tVash!ngton tlial Ihe(oregoing Is lrue end<nrrctl. <br /> �i�-/�/����L-e'� ` ���Z�' �.�jJ.1. ( 6J/t <br /> CJ ,.._-------- �- 'J -L--_ ___ <br /> �Si naturc of C miant � -- �atc - Placo si9ned(city aud stato) <br /> k°.wroa /✓/u,U�,S/l��:-/�o�.l C''/r.,:t- <br /> I <br /> I <br /> i <br /> — I <br /> ;`' �I �� <br /> �_. -� <br /> ,., ,,, <br />