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1 t. If Ihis Uaim Involves a vch!de aNd��nV�ofllsioa, pmvide your Vehidc Infnrmalion: N��__ ___ _._. <br />/Ya(c h'a Alakc Na�1c1 Yrar <br />OnYcrkNamr <br />On•niv i lnsu:mm Com,^.�ln)� <br />__' . �_ 'DnrrrYlkentr/!o. _' <br />_- _f Aonc A'o. ._____ _ . <br />Ych&/cO�rnw(s)(U2l/rJrnf (mm <br />!b. Y A'o. <br />I?. Names, addmsses and tclephone num6crs oi all persons Involved In or witness ta thls IncidenC n/%// <br />/�•r <br />13. �Mames, aAdre�sses/ a�nd letephone rumbeu of all Clty af EvcreR employces having knoHledge a6ou[ thls IncidenL <br />i�v�c�fr_1"J,�i c-c � J�iqyG!_.C� v_[±n�.�Z-`/,�v�.S`/- 5J13•/�,�/J�y l�irv � <br />C' ����iU. y Z-��_SJ.0 _.tilArV_AS r�ir.,Jf� %VI��ZY'Y-l� S.rY! c'� r��7� ---- <br />.r,t <br />14. Names, adclresses and IeicVlio�c numbcrs of all Individuals not a!ready IdcnUfled In #12 anJ N13 above who havc kno�vled9c <br />re9arding the Ilahlllty lssires fnvolvcd In lhis Inddenl, or Mnowtedge of Ihc Clalman['s te;oll�n9 dama9es. Piease Indude a bdef <br />deXripllon i5 lo llvt nalute and exlenL o( cedi perso�i s knmded�e. AUach addilinnnl tihe.els If neceswry. <br />F-��1�_SA��'14S--4J�,��2J-y�0/ DN �P.� .r_ _ _ <br />LT _. - S�nµc.c� ��n — _- <br />i'_... _ <br />I5. Uescrlbe the cause o� Ibe inJwy or dam��grs. Fxplaln Ihc cxtcnt of pwpcity los5 or medlcal, phys'a1 or mr.nt�l InJurlu. Attach <br />addiUm�al sheuts If necessary. <br />ON ��.`�' /.� -G��^ .-o-y.' --�-�,i <br />�L�U^6tir�-�./�-i/v.C,.� e%L1_l/1 <br />l6. Has thls I�cidenl Ucen re�witeJ lo law enformm <br />�� <br />salery or ucmliy pcisonnel7 If aa, whcn and lo whom7 <br />_�eS � �J/�� G'��'t, 51! ._--- - — - — <br />V. Nanics, addicsxs and Ielephone nun•�6ers of lrealllty 1112d1fdl �fOVIdr�S. MlJCh CONICS Of dll flleAl4'.I icpmts and bllllnys. <br />N/�- -- -- - - - <br />10. Plr, sc attad� documcnls lhal suppmt Uic daltti s dCegOtlons. _/.�,/ <br />�-Ci.t1L �G� CC.f � � <br />l9. I dahn Aama9cs frum thc Clty of Evcrclt In thc sum of ��_ Kr /�� <br />O <br />1 his delm Porm musl he slgncA by elther lhc Oalmanl or on bchalf of lhc Clalmant by an attorney�ImWU who holds a wdUcn yo�vcr of <br />attomcy Ior tlu pahnant, or by un altomcy at la�v udmltted to pm�Ucc In Wc Stalc uf tVaVtlngton, or by a court-aVV�ovcd quardlan or <br />yuardian ad I¢em. <br />I i•�Inic i iAer pena y of t�� dwy und�hc laws of lhe State of l'lashinglon Ihoc lhe (oregWng is Uur. anJ mncct. <br />��/ r:C.1/!L/C-J�t--c^_�5.�-- _%,"l" "� �_ _. �iW<�h-L/✓�-- <br />Signature of Claini�n[ Dile Place signed (city and state) <br />Nav.07/09 <br />