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11.If this claim Involves a vehicle accldent/coilision,provide your vehicle Information: <br /> Plate No, Make Model Year <br /> Driver's Name Drivers License No. Vehicle owner(s)Of different from driver) <br /> °wnerslnsurance Company Phone No, Policy No. <br /> 12.Names,addresses and telephone numbers of all persons involved in or witness to this Incident: <br /> AlRA& CAReln -tct3ttc.a0A41.03 - PL.• 1- a5-- a0a. - 114o3 <br /> wetl6,r mismi�- FaL , Derr �-C&t( 4..ya,s '- 5.6 © ''5' S1O 6 <br /> Clitt �..ILINAr, rret�►x ~[got we'ktMi v P .'t3,3 413'T— I/6F <br /> 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this incident: <br /> Mane. <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 incident, 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 /> 0 , Si:ter' A(dCqe CiXesXa ► 1.rt. 1 <br /> 5 Se Is "wed all► u eppace.✓netiA G�1 sc sl <br /> B. 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 /> cntM\O tOca;0 \ o-. SaWW i aQt11.WAO _ ee.FeA inia 6QSC'.(ixtevli <br /> 9ice C. cl �_ �\brn�.eO\ t`r�io ,fit io beer©t%S � hattuuatj) theve_�tl <br /> aatmc3a no, N. too r -tic it a\� +(iwee C� P_-Qs tJift s c(nandSen fc& <br /> 16.Has this Incident been reported to law enforcement,safety or security personnel? If so,when and to whom? <br /> t\f/A <br /> 17.Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. <br /> ki f A. <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$ . <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 item. <br /> I declare under penal of perjury under the laws of the State of Washington that the foregoing is true and correct. <br /> aft;t.., ob09 -an.- !-3 &Nuoils46._N . <br /> Signature of Claima t Date Place signed(city and state) <br /> Rev.07l09 <br />