Laserfiche WebLink
1L If thL dalm Im�o!ves a vchlde aoddenyrolllslon, provlde your vchlcle Infortnallon: r&roM1'o. Naae � MMN Yrer <br />DifvniS�h'amC IHNa'YlJanmNv. UrhldeUrtter(s)(i/dHcrcnt/romdnYr�) <br />Owna'slnsuamLbmprny PhancM1u. !i�/RyNa <br />12. Names, addicrns ond lciaphone numbers ef alf porsons Invoived in onvltness tn Ihls <br />— _ ,,.. � 1 c�„ _ . ,. / _. � _ _ % �_'.. <br />13. Nanics, addresses and �lephon� num!>ers of ali CYry of Evcrctt employees havin9 ba�vlcdBe ahout thls htddenl: <br />14. Names, addreRu!s and tclephonc numbc�s of all Indlvlduals not ulrcaJy IdenVOed In IfR nnd N33 nbove v.�ho have knowledge <br />reparding the Ilablllry Istues Im� �vrd In lhls Inciden', or knowledpe of thc CJatmanCs resulUng Aamagaa. hlcase Indude a brlef <br />descdptlon as to Ihe nnture an� ��'�nt of eacb person's knowledge, Attach udJillonal sheets If nemcsery, <br />15. Descdbe lhe cause ot Ihe UJun� or damages. [xplaln tlie eMent of Dro, eity loss or medlml, physt��l or menhl I�Iudes. Attach <br />addlUonalshce[silnecessary. , „ � � , , � _, , <br />�.f/ 6J1]L✓.1ZJ1••• • • • .• _ ..u���r+ <br />l4. Has thL^ Incidenl �oen reporteA lo law enfoimnr.ut, sale or mcutlty personneli lf �, when anJ W wMm7 �i�.Q/i(� • <br />17. Names, addrcsses unA lelephono raunL�:�s nf I�raunp mrd!cal providers. Alta�h mplcs of ali medlral mporls and blllin9s, <br />ID. Plcase altnrh dncumenls lha[ Ruppod Uic dalm's nllegatlon,. ` <br />12 I claim Aama9 W hom Ihe Gty nf Lvc�ell In Ihe 6um ol E} n_�?�-�•. �?Y.�-iC �1� ��Q�� <br />Thls clalm fnrm must be slgned hy e1Wer Ihe Clalmant or on hchnlf of U�C Galmanl by nn allorney-In-fact u�hn hotds n wdlten {ro�xer ot <br />attomcy for tho tlalmant, or by an altnmey nt law admllted In pradlcc In Ihc 54�tc of Wasidoytan, or Ly n court-approved guardlan or <br />gvardlan nd Iltem. ' <br />I dMare unAer penalty of Ocrlury under Ilic luws of the Stale of Wasttlnglon thot ihe forcqaing Is Uue unJ rurrecL <br />C �D��c�.�.h���... � _� - � � �;��e�.�_1���. �gao, <br />Slpnatu of almant Dato Pinceelgnud(clyenJstnto) <br />tmv, onoo <br />