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I <br /> I <br /> J1.ltthisdalminvolvesavchideaaJdenl/collision,providcyourvehldclnformatlon: ..•.. _ � I <br /> � � � A'aMNa. rlatc . ....Modc+ � -'�7'e�"r� � <br /> i <br /> OtircvSNa:nc � ' �� � � � OnitiS2lcenscY.a � aVvhirlcl7Nnn(3)�pfdRrrtnll�a�CnvoJ �I <br /> _' � <br /> .. ......_.... . .. . . .. . . . ..� _ . .. . . . <br /> 0�4n[�/S/nrmrnMComAany . {7ror.eNo. _._ .VOFyNo.. . -._ ..._ . t <br /> . 12.Namrs,addrcses and;elcphone i�um6ers of all�ersons Involved In or witness[o Hiis IncidenF., - <br /> ___._.-_ �� . <br /> 13.Names,�adresses and telephone numbers oFali Gty of Everelt em�loyces havin9 knuWledge about lhls Inddent: -. i <br /> �YLU.✓ k Syol � ec' U� S ~ ,�S`� - �`'lG7 <br /> __�_—.. –•- - I <br /> • � I <br /> 14. Names,.addresses anU telcphonc numbers of all IndNiduals r,ol already Iden08ed in #12 and A73 abovc who have knowled9e <br /> regarding the Ilatiiliry Issues invulved In thls Incldent, or knowkdge ot the fJaimanPs resulcing dunages. Please Inciude a bdef <br /> descrlpdon as to�the nature anA extent of each person's knowledqe. Attath addiEonai sheets it necessary. � � <br /> �`.s� r�-'.__�—P��!� .,.`�"�..� ������r _�I�S - so 3"� F�7, 3 I <br /> � <br /> 15,Destribe Uic wuse of the In)ury or�damages. Explain the e�ctent of properry loss or mediral,physital or mental InJuncs. Attach • <br /> additlonal sheIels if neceszary, � ' <br /> . (�.�c�'t L�'�. 4 Nf+� . S f� tr�G � � o�GIn..G Gl l 1'l `.Q.�S C I�c=� <br /> e ...�...5�,.___� �,-- - . _ _., : <br /> r�VC� -�� . ..�nCi. ��.�1� 4 0�-l� �n S�OIQ�$'.✓� l� � ',` <br /> .�O_S C-' L,,.e��. _ -. .. . <br /> - - , . _. _ _ 1 <br /> — -`------' -..... 1� <br /> , <br /> .._ .—.__�»_._. .. _._� ..,_.. . _ . . . � <br /> . ....-._—.�—�.--..-- ! <br /> 16.Has this Inddenl been repo�tcd to law en(orcement,sak.y or secudly personnel7 I(so,when and to�fiiom7 <br /> _ � . . . _ .... . . . . . _ -' e <br /> 17.Names,addrwscs und tcicpNone numhcrs of trcadng mediral proviUers. ANarh ropics oF SII mcdlcal rcporL and bililn9s. � <br /> . . ---. . .. . --'--� . . . . . . w ' <br /> � <br /> �--._ . .- . - -_,,... , � <br /> i <br /> �— ` _......_ . . <br /> -IU.Piease attach doameng Ihat support Um claim's allegatlons. � / � I , <br /> -�-0 U L d�`.'�P_.4�4'�1�"\c� <br /> '19.1 dalm Aamages tmm the Ory ef Everett in Ihe sum oF g_._,_._ .. .__, i <br /> 7hh dalm form must be si9ned by elther the Clalmanf or on behalf of Ihe Claimant by an altomcyirrtacc who hoWs a wiitlen powcr nf i <br /> altorn�:y(or lha Claimanp ur Iry on attomey al law admittcd 1n pnctlm In the Slale of Niashington,or by a murtappwved guardian or i <br /> guardian ad Iltem. ' <br /> 1 detlam unJer penalry of perJury und�Uie IaN•s ef lhe Statc of Washingla�lhat lhe forcgoing is true nnd wrteck. <br /> _ /1V�/��/l�C�i\. ..--�-.. .C�_--?) '� l � � <br /> �SignOtureofClaimant Date� � Placesigned(cltyandsWte) � <br /> Rnv.07109 . <br /> a�a <br /> � <br />