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i <br /> ]].U tFis Na�m Invoives a vehide accidcntJcollislon,prwld:your vchlde Nformatlon: �� <br /> l4ah+A'o. Afake � '--�.YoON 1'm� <br /> n:n-�/sNamc ' —� OrfiMl'aUtmSPA'a VP/idPO�'f1H'(cJI�`dliarnN�rmrYlvmJ <br /> UKnaSGrs�nanceCrtnp�ny —�---- � VhmeNo. -- PrhryNa � ' ------ <br /> 12.Names,�dtlresses and tetephmc numbcrs o(all per:.ors Involved In or witness to Hils IuidenL• <br /> /� <br /> i3.rlames,addresses anA telepha�:numbca o{all Clry of Evcrett emp'oyees having Vaiowledge abn�t thls InNdmt� � 1 <br /> / <br /> 1C. �James, oddrases and tdephone number< of a�l individuals not already IGcntlficd in �12 and �li above who have knoivled�e <br /> reguding Gi_ Ilzbllity Issues Inrolved In this Incldent, or knoHledgt of the Claimanc's rewleing damages. P7ea:c indude n brief <br /> descriptimi as lo lhe na:ure and eMent of each persen's!viowledge, Atttch addillonal shtt[s It nems<_ary. <br /> /'—.. —_—._--� —_ . _—_—_.—__. — -- _ —__-- <br /> 15. Descrlbe the cause oF the In)ury or dimages. Exp!atn the e#ent of propttty loss ar rncdiml, physlal or menta(Injurla. At,:,ch <br /> addiuonal sheets If necessary. � � � <br /> .��cvcrr l��:c/_r:�. ���,; �tv_� �a-�,� �--�� `v.��-,��'� �,, � I <br /> �'�..�t�'t��s f����als7_.� y/�..�-_�,—� _ _. <br /> 16. Has thls inddent be•n repa ted to law enfarcement,sate,y or mcurity pesannel? If�,when xnd to whom? <br /> i <br /> 17.IJamcs, addres,es und tclephone numtea of treuting meAlcal pwYdea. Attach coples of all med:ral repoNs and 6tliings. � <br /> 1S.Please attach dotumcr.ts tha;suppod ihe dalm's alleg3Nons. � <br /> rtt ,,` I <br /> 13.I clalm oamages from[he Oty o`[vMctt in the sum of 5_ __,____ �1 J 1�(�. `���f{y/�(��C� �. I <br /> ihis cla�m krm must be slgned by eilhcr the Clalmant or on behnl(af the Oalmmt Ir/an atto�n^y�ln-hR vrno holds a writfin pe.vcr of <br /> 3i[otOq'(nt th:Clalmant,nr hy an aNrxnzy at law admiifed to pradi<e In the SLilc of lVnsMnglon�or lry a courtvppiovtd gudrCtan ot <br /> 9uardian ad Ilicm. <br /> 1 Aeclaf undu ptnal.y of pelJury under the Ixws d the State of lYashington that the foregW.ng ts true antl wqcct. <br /> �_--- <br /> ���� �W"-'�='--- `I i3 zu�.�__ ��rec�tf- f}� <br /> �S nature of Claiman� ate Place signe�(city and state) , <br /> v.07109 <br /> a � <br />