2702 BROADWAY 2022-05-23 - Laserfiche WebLink

11.If this claim involves a vehicle accident/collision,provide your vehicle information: Plate No. Make Model Year Drivers Name Drivers License No. Vehicle Owner(s)(if different from driver) Owner sInsurance Company Phone No. Policy No. 12.Names,addresses and telephone numbers of all persons involved In or witness to this Incident: 6vin pto A 0nc i S lc . .&)d1Q.1g0 1 U'1a(an 'A,toad} k( 10 nc rou,9b,`ik-evi2.�n .c. Qu,.r , 35r-c (24Ja� ci... . ')t� ( c,3�JJ .cl el , k t)ph o►n.o. 42.5--252-223,ii. .v�C CO0A c4S-c1t... ' •1 u1 ( Foie\v c toter-e-'c nth q%Ni 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this incident: E;ex-.e. t t'u-a nit lt.S Jei� rn Pkss ee ,, 9 av Lr ,Show k c13, R&.rk ettrkvir- , S4-e.ite bahUV\ , C J e..�sl..t [.j jai 'f� Oart 4� u • a h 14. Names, addresses and telephone numbers of all individuals not already identified in #12 and #13 above who have knowledge regarding the liability Issues Involved in this incident, or knowledge of the Claimant's resulting damages. Please include a brief description as to the nature and extent of each person's knowledge. Attach additional sheets if necessary. Vi V fl \ lL r �&IY1 C... V2�c ��ec Olt in C Cfl lei 4Z4.-- 2S 2-levucl `f rtAil Chrirli,uAQ eCiar ina --N,.g. AncaM up S er u Ce. -rcr-tha Ce8A-631;(11.4th 15. Describe the of the injury or damages. Explain the txtent of property loss or medical, physical or mental Injuries. Attach additional sheets If necessary. G.&D- 16.Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? 17.Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. 18.Please attach documents that support the claim's allegations. 19.I claim damages from the City of Everett In the sum of$Cm3thatki 4 5, Z 1' 3 vA ore v O L A This claim form must be signed by either the Claimant or on behalf of the Claimant by an attorney-In-fact wh6 holds a written power of 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 guardian ad iitem. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. 0 .. 10/ ii/i 3 Ale it viii t;,- klk-i fl Signature of Ciaimant Date ma)signed(city and state) Rev.01109 to ks.....-wa �Ntocb ivl\ic\--\-'2- vet A .(7'.__ N _