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i <br /> I <br /> 1 L If thls dalm Invofves a vchlde acUden4�ollision,provide your vehlr'e InformaUon:�_{+,,�. __.___ <br /> l7nM No. Alu�'r Model Year <br /> ON`rYs N.ime O�inv's l/(rnm l.'a. � ✓chide O.vrtei(s)(//r64cmnt/rom dniv) <br /> OwnaY Insur,mcc[orty;any Phare Nn. PofiryA'o. — - - <br /> 1]..Names,addresses and lclephonc numbcrs of all permns InvoNed In or witness[o this Ind9ent: <br /> .�-LG�1pP.1 (��,1L •- SP�1- _�—J,1_�'_Q�—F-E'_'t��" �1 %f�S-�S�� '(�4 <br /> �r.��<��l�w�t - �d�w c.�r�.�c���a�(J�-�as-as.�'i�z?9. <br /> 17,Names,addresses and telephone numbers of all Clty of Everett employces having knowledge abrnrt thls Incident: ' <br /> C-.��tS G����r .�:�CYI �n��-�i1Qj�1.�.�1�'�1u�7� N:� -as��- b�s9 <br /> ���r��F._� PG _��-�,o�tsP Si;,-__����I�JY�;R2��1�t�S-�57-$`��9� <br /> 14. Nantes, uddresses and telcphonn numbcrs of ell Individuals noI atrcatly IdenUfied In 7117. and k13 above�vho have knowledge <br /> regarding lhc �lablllty issues Involved In this mddent, or knowledgc of the qaimanPs nsulelrg damages, Plcase indude a bdef <br /> Qesclptlon as to ihe nalure end exlr.nt of each person's knowledge. Attadi addltlonal sheets If necessary. <br /> �in1-��S��-r^ - (� 23-1�Y�Y1�2��d�n._-F=��.Pp��,UIQ - �f2S - �S 7.- t44/ I <br /> �rnh,_,1��,.�,n i� _ (o��. ��ua�o.n (�e�P tg�i,�PfTU��l7s:_3_L9�s� <br /> �e ��� a al S.nvc ran �'i-�4�or Stt�u����A a. .lcA �arrl vrc-l���.rS <br /> ]5. Descdbe lhe caum of the InJury or dam�gPs. Fxplain lhe edent ot property loss ar mcdlol, physlcal or mental InJurles. Attach . <br /> additlanal sheets ILn�s�ary. <br /> C. � p� <br /> g-a�-�3_C �U=t���S�r=�'US i��q CO.111 S � \ Ulcti�'e�if Q�?^ <br /> �.v�__.�`lYclv au•c _ ��t�t� as �nt�_�O" t H a�1e p,� �u. 1,n eS eS �I <br /> I�.�� �1 C/o 5�� �P +4__� <br /> �laV�'f��\� ,h,.�U'��_c,fa �50= ~ 1 � P. • IR <br /> N-�p�'L��LY1�3S ���(-n�(l�, Clnnc�J1 C�JN�YfliT4'�� � CGYYS���' <br /> 16 Has this hiclAent heen repo,rteA to law enforcement,safery or secmlty personnel? If w,when and to whom? <br /> .�j ��- <br /> 17.Namizs,nJdr�sses and telephnne numters of trentin9 medica,prov�Aers. Atlach coples ot all medical m�x:rts and Blllings. I <br /> _�-�Q -- -- -- <br /> 18.Please attach documeNs tha[suppoit Ihe clalm's allegaUons. <br /> 19.1 da6n damages fiom th�Clly a(Everclt In the sum of$���Q��-�m�'p� . <br /> Thls dalm form must be slgned by etther the Gafmant or on Aehalt of lhe Claimant by an altomel^In-fact who holtls a�vritten powar o( <br /> altorney lor the t7alrtwnt,or hy an attorney at la�v adm�tted to practln�In lhe State of WashinglM,o�by a murt-approved guardlan or <br /> guardWn ad Iltem. <br /> I declarc under penally ef pei�yq�u.nder the laws lhe state of Washington that the foregoing Is tme and conect. <br /> '"�t`+�a� c.,�. �a-�w osZ� IU��1- �3 l�.n 4,e-4�, W IA <br /> V, Ce-Q.wc_Q.R 10 -7.9_. 13 £v-�...�i�� �� <br /> Signature of Claimant Date Place signed(city and state) <br /> Rov.07109 <br /> �� ��/1� I <br /> V I <br />