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11.If this claim involves a vehicle accident/collision,provide your vehicle information: !Y 4- <br /> -- - Plate No: - Make - Model Year <br /> Driver's Name Driver's License No. - Vehicle Owner(s)(if different from driver) <br /> Owner's insurance Company Phone No. Policy Na <br /> 12.Names,addresses and telephone numbers of all persons involved in or witness to this incident: <br /> • <br /> • <br /> ‘13.Names,addresses and telephone numbers ofC.? all City of Everett employees having knowledge about this ii}ncident:r <br /> ce, „kJ/ <br /> fre0 Et.)./112- — o OlCia <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 inddent, 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 /> /6.4,11A(I,P JJFa 4pJ rn c/ J��,.�. IT1__5'4Z ,S <br /> 6—a414 ae Yt/r !'D /-- Kg—J.5.'- o e ')8, --M <br /> g&g/—A / '7:4 AV ,A.I ?g05 <br /> 15. Describe the cause of the injury or damages. Explain the extent of property loss or medical, physical or mental injuries. Attach <br /> additional sheets if necessary. <br /> • <br /> <� © 1 .'. Jd. /. _, fte, 1 <br /> oi"_ c?.1 IN . -BWMAIIM,5111 , 111107 !re i <br /> 16.Has this incident been reported to taw enforcement,safety or security personnel? If so,when and o who . - y1 <br /> Af4 <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 allegations. <br /> 19.I claim damages from the City of Everett in the sum of$ 7"! Tti aC�r f <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 declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. <br /> (5e_e4e --1111 <br /> Signature of C!" t Date Place signed city and state) <br /> Rev.07/09 <br />