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11.If this claim involves a vehicle accident/collision,provide your vehicle information: <br /> Plate No. Make Model Year <br /> Drivers Name Drivers License No. • Vehicle Owner(s)(if different from driver) <br /> Owner's Insurance Company Phone No. Policy No. <br /> 12. Names,addresses and telephone numbers of all persons involved in or witness to this incident: <br /> �', -M+✓r� P�c�L 47 t 1 tam v c icj t a 6 (4'zs) ib <br /> 'AA-14- 51 iA- ? r &A v: i. �7i) t l Z-03 (425) 2STb•2)32 <br /> t"1i2l Po l6- V P ,e t 1 p ..i;c .v. 1)9t,cicW5(425-) c 7e ( <br /> 13.Names,addresses and telephone numbers of ail City of Everett employees having knowledge about this incident: <br /> f-itkP_tz--i 14-e 1 pores b t=� p i. � •� 7 v�" <br /> rpkvi rl.?l?y �Pc.,�3c., <br /> �i/ - u?ci 4 , ecep so0 - S <br /> 42Sf 2._5�� 556 <br /> 14. Names, addresses and telephone numbers of ail 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 /> °T CLA"•T ex-3 (4e-r X-nrz c. C.)W-t,.e) <br /> o Sexy 1`c:e b .ct,sAe er �-,EL >c - <br /> 16. 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 /> r T EV-OM O1Ar61-4 -41 S t N 'LoopG L VDD,oro ! oil - y i4-l7io <br /> N 00 Z9 WrstT ?t. ,sr- -12oc,&S, DPcg -. ts� <br /> e Paz. @.(Arc- j l-SI . 'tat. t Lir t)17 4' FLTAsio t t-Yf o <br /> °LAt- Mt"- .rr 0.A(90E--0 � ca _ 1 ac r. . L_G ) L... P )D <br /> 16.Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? <br /> Sl tgzc c FwA , Dt%r . O ) V•Z t- (3 Y l t 0-a-4o I4 c I DU '1 7:3604 <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 /> 19.1 claim damages from the City of Everett in the sum of$ .361 t0 00, q3. <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 /> Si n ture of Claimant Date Place signed(city and state) <br /> Rev.07109 <br />