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11.If thi;daim involves a vehldc actldent/m�lislon,provide your veliidc InformaUon: __ <br /> vlaten�. Na4r nURe! Yra• <br /> n�vcrsna,ne On�riY[lanscNa. YthirMU:mcr(s)(fd�9r;errllromQ�/rrrJ <br /> ' Own�i Irsurana�Conipa�� ! --Fhnne h'n -—— �4'� — I, <br /> 12.�amec,addresse�and teleplwne mimb�Ts of all per.mns involved In or witness tu lhls Inciden[: <br /> i <br /> � --- -- - <br /> I 73.Nnmes,address^_:and lelephone numhea of ail Qty of Evere;t empl�yces having Imrnvlcdge.boul llii;Inddenh <br /> � �4 3Q 1ni e�,n o rr �1uc�4�'1A i;v e��(� <br /> y r�t � (1�,� 10..�_�?oC�_C'esL��{- C-v_�r�:J_(�` ��lzv) �25�1.���Za' <br /> _����es_��i� _._32eD Cn�s-1� sl- Fin���f( `�p7al �1�-�,,�� T�z:.3X <br /> 14. Namcs, aduwsss anA tclephonc numheis ol all Individuals not already idrntifeA in b12 and Al3 ahmc who havc Imow!cdgc <br /> re3ardL�g tha liabillq� Issues InvoWrd in this InrIA^nt, or Imowled9e of the Claiman['s �esultln9 damages. Plcase InduJe n bricf <br /> . Aexrip:inn as to lhe w[um and e,etent nf cah permn's kno�Wedge. Attach addNonal sheets if necessary. � <br /> _� S�d�" � ]?17�E(2.1�L`Y�__ S I!E(��_ _ZQ�.�,�0 ' 4'Sr2J I <br /> i <br /> GIlF �s n{(1 t ,pn1 % ` �1(���L�?��S� JZYB �}_Q��S�C��__KS_�Zy � <br /> .�iG_.�;�s�,fl�_.1� � �f __�Z6.6=�44_�i91 — <br /> 15. Desolbc the cause of Wc In ury or damage;. Explain the exlent nf pm�xity loss or mediail, phy<_Ical or mental InJurics. �ttadi <br /> " aJdltlonal sheecs If necc„ary. � <br /> --�1-o0j�—� -��ll1-ES'.-1,,�ar�P .tt�c�fi-C15r9_QN��+1rJ.�Rr—�a9�t-- . <br /> � -��� '�{�.LC'r C�'QLt�+`�—�_2���2.OIJ—�1='tt�'JN�.(t—'�-CY3nC�l <br /> {'t�QL1-4a'�_ C�a�1�CrY �iF`/ ,`�AIC�-�C't--11�7 `i�-�kL�ll�--- <br /> :!'jR�����i-_ls__ l,��tlfSi nn1 rGJ1:ILl. prJi�—��ILict��_9��09 atA_i''f_'celi(JC�rs <br /> ��7-n (�eeF�r�4mC�-}_"Ctc�1I{uJlu. inl��i_i ��ii:�,�, ��r��r <br /> � 16.Has this Inddert been rcpoded lo Lnu cn'cr�icnt,safely oi secunq�Personnel! if so,when and lo Whnm'1-D�����'� ')��'n�}/ � <br /> (�f111��� � <br /> _�'(�Qf�._`�� " as='-dFFiCi91��(�S�iAr1 �looiArl�,) I � sa�- --- - <br /> . J l� �1���U 1n;p P.L�'. <br /> 17.Names,addresses and tcic hone numbcrs of lrealln9 meJlral pm�4d�s. Allach ttfPles of ail medlral mpmts arcl tllliln95. <br /> __._—_ . _ _ —' ._ ____'_'—__--_ .___—. i <br /> � 10.Plcase attadi daumenLt lhat sup�mrt Ihe dalm's alle9alinns. I <br /> . 19.1 elatm Jamages from lhe Clty ul[verelUn thc sum o($_. _ ,_� , . . ._—.. <br /> i <br /> "Ihis da!m forrn must bc sined by el:her Uit Claimant or on behall ot Ihc Ci,Inianl by an NlomeydndGCI14�10IIOI�S J WlltlCll�IOI'JCf 0( � <br /> aflomey(or the Clalmant,or hy an allomey at law admittcJ lo pradice In Ihe State o(1Nashin0�on,m Ly a caut-approved guardien or � <br /> , auarAian ad litem. . I <br /> 1 d�clam mider penalty of pr.ijmy unCer the lan•s of the State of l'Jashingtnn that the foiego!ny Is true and correct. <br /> 1 ����1U�1�,0��`(�� '��� �a �-�s�]J3 _. '-_�it�:c:l� t,�l c� `�n 20� <br /> � gn ture uf ClaLuinf Date Pface signed(city ond s[ate) <br /> na�.wme <br /> � � I <br /> /t �il� � <br /> � I. <br />