2718 BROADWAY 2023-04-11 - Laserfiche WebLink

11. If this claim involves a vehicle accidenticollision, provide your vehicle information: Plate No. Make Model Year Drivers Name Driver's License No. vehicle Owner(s) (if different from driver) Owners Insurance Company Phone No POIIcy Na 12. Names, addresses and telephone numbers of all persons involved in or witness to this incident: 13. Names, addresses and telephone numbers of all City of Everett employees having knowledge about this incident: 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. IS. Describe the cause of the injury or damages. Explain the extent of property loss or medical, physical or mental injuries. AttachBKQ -O additional sheets if necessary. W &M S1 2-cl '�11 21C)i 3 DI,V &T" ` z71 ITS gr—OA-Usa AiJ TO Vl -=-, t. L3 LJO 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. `P4 {�; IT % VA6 F09— <,-- LA 10 �4 U MQ 01�- Tb G-f�-r 19. I claim damages from the City of Everett in the sum of $ . 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 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 litem. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. LAS Signaffire of Claimant Date \ Place signed (city and state) Rev. 071139 .