|
11.If this claim Involves a vehicle accident/collision,provide your vehicle Information:
<br /> Plate No. Mike Model Year
<br /> Driver's Name DriverlLicense No. Vehicle Owner(s)(/f different from driver)
<br /> Owners Insurance Company Phone No. Pal/cyNo.
<br /> 12 es ad ire es and tel hone, ofo,g4d I o ttne this ipddent;
<br /> F�CaUtC1 �V1� Y] '1�0 � �.}-{ ,r,D t !-.�.VL3,.�✓'- on. V1�eSt�-ea�.,
<br /> at i o b t kr-�k q'a. (,2,2 `-i(,Z ( 1..-_tA..t - L''t.. lAi_51.-t_
<br /> 13.Names,PSr sses and le i-`i numbers of all City of Evere em oyees Itav vd�g ab ut thi en {'6
<br /> Fuprt t (t-t-,I(1-1 n14(t I rad Ca\ v\ e, .w
<br /> Th - 4, G(ch-z_vte v(- C2 5q- ._ cfa 541.)
<br /> 14. Names, addresses and telephone numbers of all Individuals not already Identified in #12 and #13 above who have knowledge
<br /> regarding the liability issues involved In this incident, or knowledge of the Claimant's resulting damages. Please Include a brief
<br /> description as to the nature and extent of each person's knowledge. Attach additional sheets If necessary.
<br /> Air.. ubNr k-,.�-24, Le o -2.,--. 12... 0 :.f--P i.,u.--- r -
<br /> �
<br /> 15.Describe the cause of the injuryof loan es. Explain the extent of property loss or medical,physical or mental injuries. Attach
<br /> additional sheets If necessary. F 3
<br /> 0'� y �irs�0 Au(pa- �,cc.�. & Ct a. SV--1 trCi t v, p c,�.,t� Qyna
<br /> • 'LQ, 4`t.t O d`r-(,c I v' el Ors.. On/ ., 10 Gt_eifa rlivt��: L..J..Psf''.(_, G.12,' a ie3 k tn[s,}
<br /> Q.. Ina --h A b _?s1'f.r---=e. . - x-t l k t :p C�-inck �Q S ow-eir J
<br /> of-l.tn. 1..06 -��y,Filial.(H no\uNak , ' lL)\\b\ �1JCc..6Q '\.Jb&n,*�,,r\ tfa S
<br /> COUP�eAD it ,,,, c�(--u� /I�-l'c I e ' , ` 1,' IIN ve ` 0 -.-
<br /> 16.'Yias this Incident been reported to law enfoP e�ieht, fety or s cur per ne I ,WI a and to whotn7
<br /> a w.. ay.ck 1-rn .G 'Gu�IX'=e*- . 1 of
<br /> \` �VA.6k `tL'\!x et_
<br /> d
<br /> a�, vu¢. Qar ...
<br /> 17.Names,addresses and telephone numbers of treating medical providers, Attach copies of all medical reports and billings.
<br /> 18.Please attach documents that support the claim's allegatio 7JA "
<br /> 19.I claim damages from the City of Everett in the sum of$ l .)ovvf ° 'tom""
<br /> This claim form must be signed by either the Claimant or on behalf of the Claimant by an attorney-in-fact who holds a written power of
<br /> attorney for the Claimant,or by an attorney at law admitted to practice in the State of Washington,or by a court-approved guardian or
<br /> guardian ad litem. ..
<br /> I dedare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
<br /> 16`'� r am. V 9'/�U/z/A 3
<br /> Signature ant Date Place signed(city and state)
<br /> Rev.07109
<br />
|