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1 i. If ;hls da6n Involves a vehide accident/colltsion, provide your vchlcL Informatlon: _. �S > <br />NatrNo. MaA'e A1n�M Year � <br />—'_ _—___ _.._.--._..—.—.—____ -- _—�� � <br />O�/v;r;Na�+e OrAr1slJ.'ensrf✓n. UrludcO�vn<r(,)p/diR'emn!(romCAKrJ � <br />—.—__--___-__._.—.___— . ._'_. __ _.--____— —__—__' �� <br />O.:na'slrsuranrn[o,npany PhoneNn. Po.kyh'o. „1 (L,j <br />�rs o � <br />]:. Names, addresses and telephone numbers of all permns Invoh�ed In or wllness to ffifs Inddent: _�� <br />]3. Names, addresses aud lelephone numhers nf all <br />� <br />('-rG1�'?_CL �i�__ i �)�_(i � _ � 4� ~S <br />- � o <br />-—--- — � <br />— — N <br />or Evercu eptnm <br />c� <br />about th(s Inddent � �� <br />�' 2�1 � � �' � .i � <br />��„�S �n , �. <br />IM1. fJames, aAdress=5 and tefeplmne numhers of ali Inalvlduals no! already Idenli(iecl in R1). 2n�' :13 abovc who have knowledge <br />regarding lhe IiaGlllty Issues Involved In thls incident, ar knowledpe cf Ihe Cfalman['s resuP,ii�y Jamages Vlcisc indude a brief <br />descrlptlon as [o the naWre an�l extent of each person's knowledge. Altach additlonal sheeL� fr necessary, � i <br />I5. Describe the cause of the InJury or damages. Explaln ihe extent of property loss oi medh�i, p��ysical or mental tnJudes. Alhch <br />additlanal sheets i necessary. <br />1�1��kQ� �keo cviwc� b� f�untf.,1" a�f r�ll�; ��ei.�aan.. �'I�r� �.� <br />, ;�n. hu�se <br />�[ y �A�vu.� •� �-,ivi.�c'�lyii.i cruvi l � -- -- -- -- <br />16. hlas thls Incident bcen reportcd to law enforcement, sa`ety or :.�eurity persnnnel7 If so, when and to whom7 <br />17. Namcs, uddresses and lclephone num6crs of treatlnq mcdlwl pruvlAer;. nitach coples af all mediG�! fCprnL. and bllllpgs. <br />� l�ec�e,yii�y y���v� c�ca.in i'.�ne��c�riVe : So i11ar ruvinr9u.`��Pr- <br />— u-ai— , __ —,�1' . , _. <br />�U <br />I N__ 2•t�l U 1'�;:�'�-�-jS � ���cr €� �o��v� d 1u�1�2r d Y�1�ti2+,�P__- ' r <br />lU. Please alWch documen[s that suppo�t tlro dalm's alle9atlans. ��, �, �) �� ��-- l,��,v e�S 1'+1l�� <br />t le���'�� 4�i�' W�?-�'�'r iYGc'�}�f' .9j;�W <br />19. I clalm danmgc; from lhc City of Evcrelt In lhc sum of y ---_ ) <br />�of' �a5n_vUQvi�" G�eavtM, <br />Ttds clalm form must be si,ned hy cither Inc Clalinant or on behalf of thc [laimant by an aUornep-ImfaA who hold, a wdtten power oF <br />attomey for the Clalmant, ur hy an aUorncy at law admitteJ to pra�ilce In the Stale ot Washington, or hy a oourt-approvcd guarclian or <br />guartllan ad Iltcvn. <br />1 detlare under penalty of perJury u,�der the laws nF the State of Washinglon lha[ lhe tore9oln91s Iruo and correct. <br />�u�,� � !�¢�'� �`����2U�?� '1;�� 3�� 5i` ��%1ft� <br />-- _ — — - — <br />Signa[urnofClaimant Dat Placesigned(cityand take) <br />Rav. 07109 <br />