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11. if thls cWim Invr' :s a vehide acddenVro�llsion, provld� your veliide Information: <br />� � . - � KiteNo. P!ake Afodc/ YNr <br />OnvNsNamc � Onrrri�tlarorNa � ✓ehklcO�merjsJ(iI0:71sm7homAmml) <br />O�mrrilnsu.mreCo,np�n�• .. !'/aneAV. lhUqNo. ___ .._ <br />]2. I�ame., adAre�es aixl telephonr, nurnlir.rs of all ��c�mns involvcKf in or witness to [bis indden[: <br />13. Manms, aAdress�s and tr.lephone numhcis of all (';ty of [veielt employeFs havin9 knawled9e about lhis IndAeaL• <br />14. Names, addresses and [elephone numd:rs uf ail inJividuaL not alruidy idenlified in N12 and Nl3 above �Nio havc wiowledge <br />regardin9 Oie liablllly issues involved in this indden[, or knowled9c of '4c Cldhn�mPs resttltlng Uamaqc;. Nl�tse Indude a brief <br />desr.dptlnn as ro Ihe nature and edent of each person's knowleA9e. Att: �' � Iditional sheels if neceasaiy. <br />I5. UeunUe Ihe caux o( the injury or Aamagex. 6cplain the eztent of property loss or mediol, phya�l or mmlal InJurles. At6ich <br />addlUonai 5hcr.is if nec�ary. <br />iG. I las lhis Ind:lenl bcen reported lo law cnfortcment, cafety nr sccurity persunnel? lf 50, wf�en anJ lo Hiimn? <br />I), Ndrnc;, addies.r_s arJ telc�dione number, o( treatin9 m�dical yrwiders. Altadi cnpic; uf all mcdi4il ie�qrts and blllings. <br />ilt. Pleasc altadi documen6 tna[ suVport lhc tiaim's allegatlons. <br />19. i rLiim Aamages Iwm the (ity of Gverr.tt m the sum of g_ __ <br />ThIs daim (oim mu� bc si9ncd lry ci[hcr thc ( lalmanl or on bchalf of I�c Claimant by an attornc��imlact whu hulJs a writNn �v:er o( <br />atmmiy for Ihe daimant, or I�y an attamey at law admitted to practict in Il�e Statc ut Wa,hln9ton, or by a[o•irt-approvCA 9uardian or <br />guardian aA Iltem. <br />I dttlare undcr penally of perjnry unda the la�a; of Um Statc of VJashin9lon lhat Uie forr9uin91s tmc anA wnect. <br />c�:; -�c'_c�c r>� _1.�� -- �1- �o -�?> _l�,«�,_,L 1.13>�.n,.x a,_ ,.t <br />� �� � D�te Plaeesi ned ci andsWtc <br />Signature of Claiman[ 9 ( h' ) <br />Hav. 07/09 <br />