2126 WALNUT ST 2022-05-17 - Laserfiche WebLink

11. If this Balm Involves a vehlde accldentloolfslon, provide your vehicle Information: plate No. Make Mbdel Year LYiverY Name flArcr'S [Invesa Nu. Veh'do Owner(s) (ddy7erent fawn dA'er) Ormcr4?nsuramef 1wv -- pAane No. Po3YY AD. 12. Names, addresses and telephone numbers of all persons Involved in or witness to this Incident: 13. Names, addresses and telephone numbers of all City of EVerelt employees having knowledge about Inls Incident: 14. Names, addresses and telephone numbers of all Individuals not already Identified In #12 and #13 above who ha ' mwtedge regarding description las do thle nature and extent orthIs f each perident, or son's knowledge, Attach additional sheets If nmessarye of the Clalmanifs resulting ages. Please Ine a brief - . he 16. Itas this Incident been reported to law enforcement, safety or security personnel? If so, when and to whom? W�,' •6 We C-1 � , D; s'Pol+A }- Cafem i, "(9,m . -- 17. Names, addresses and telephone numbers of treating medlral providers. Attach copies of all medlcal reports and billings. 16, Please attach documents that support lire claims allegallon5. 'I q'§V write-� .4qc)( �wr� 5'40,00 },( JglVej ItS{q��COtr 19.1 claim damages from the City of Everett In the sum of $ •-.}--�• vd q This claim form must be signed by either the Claimant or on behalf of the Claimant by an altomey-In-fad who holds a written power of attorney for the Clalmant, or by an atomey at law, adrulded to practice In the Stale of Washington, or by a coutapproved guardian or guardian ad Iltem. 1 declare under pena of perjury under the laws or the State of Washington that the foregoing Is true and correct. v� •A- � signature of Rev. 07109 (dty and