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11.if lhls dalm Invohes a velilde accident/colllsion,pmvide your vehlde Ir.(ormallon: _ <br /> %ah No. 1'aku Ncdcl Yavi <br /> DiAtvYNanre OrA�vt�hniu!!a u�,�dern�•nr7sJ�de;.rrrmr.rwndn��q <br /> Owncr47nsuran<rCanpany /NoncNo. !L•/'ryAb. <br /> 12.Names,addresses and lelephone numbers of ail persons Involved In or w:L„a,!o Ihls InddenL• <br /> �a1�E S�j-,7.it1 i�..clwe��1b,Ea��A 98zo�, 4�S•3oe•b�z _ <br /> cT „ .fl� 2b3z�w�¢2�E.��35 taE� L►1A96Zo1 �t25�319• i55s <br /> 13.Names,addresses and lelephone numbcrs of all Clry nl EvereR cmplayces having knovdMge ahout lh�s InUdenh <br /> n <br /> ��GNaD �khE dis-��r.heR u�ao in eo en �'' eb•��. <br /> 14. Namcs, addressrs and telephone numhers of.II Individuals nnl atready IAentilled In #12 and u13 above who have knowtedge <br /> te9ard!ng lhe liability Issues Invob�ed In this Incldent, or Anow!edgc of Ihe Clalmanl; rcsulting damages. Please Indude a bdef <br /> Aescdptlon as lo lhe nature and eNent ol each persun's knowled9e Altach additlonal sheels If necessary. <br /> f 5.Oesctlbe lhe cause of Ihe InJury or damaga. Fxpiuln lhe edent of property loss or medlcal,phys'cal or mental InJudes. Atlach <br /> addillonal sheets If n(ec�essaiy. <br /> �SEmGn�r 4 te�u.-�C �yE �o ee.mh�nso s6�E¢ $�rn¢m�1R�]ac�c.-`.`(� a..._e�^5 '�r <br /> 2 hea+y ua+ns�.«+s. IZs��l.ttF���s �L.IoE� .and in,stallE,ps.�n„p.p�..r,p� <br /> �Su6 ��ec�P. � <br /> psc- y�a,i PSE- �'G�y//, oo���r�z y, sY�- s93./� - <br /> 7oTdt �" � �9. <br /> 16.Has thls Inddent been reporled to law enfm�ement,safety or security personneR If so,when and to whom) <br /> Scc � �3. <br /> 17.Mainrs,addmsses anA lelephone numbers of treallnp medlcai provlders. Atta:h coples ol all medlcal reports and hlllings. <br /> ^�P <br /> ld.Plcase altach tlo:umenls Ihat suppod lhc cla'm's allegations. <br /> 17.I clalm damages Oom Ihe Oty aI Eveiett In Ihc sum of$ �'��•�� <br /> lhL•dalm(oim must bc slgnM by eRher th-�Clahnant or on behalf af lhc Cla!manl hy an altomcy�lndact who holds a wdtten power of <br /> ,Itomey foi thc Oalmanl,or by an altomey at law admllted to pracUce In Uie SWtc of Washinglon,or by a murt-approvcd yuardlan or - <br /> yuaidlan ad Iltem. � <br /> �i Acclam w�penalry I p r y under lhc laws of lhe Statc of Washln9lon lhat thc foregoing Is lme and mrmcl. <br /> '��1--� �0 3 �� �,�'�.��+ �a 9s�s7 <br /> Signatureof laimant� ,/ te Place Igned(cltyandsWta) <br /> Rev.0710¢„_��?� ��u� L�� <br /> O"!/I �j -Cf4 <br /> /// <br />