7318 EVERGREEN WAY 2022-05-24 - 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 Owners)at-different from driver) Owner's Insurance Company Phone No. Polk y No. . 12.Names,addresses and telephone numbers of all persons involved In or witness to this incident: Ne-kian (' scir,k/ Z()Zi2 12 k— / _4VL OMetc'zo i ( ) ge-7izq ch rr'r U LL5ur ; /'fit 75( 1 Si^ 5e_Jtept lve -F 1.b104 `AEIt4 0125).J7f /no T ou rd 17ri's, ma Al aO/- r 1 j/ip, // u1 ,4 . ' / p)3/o. 6 2 tZ 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. 15. Describe the c�us of the in ury,cir;.11iimes. Explain the extent of property loss or medical, physical or mental Injuries. Attach additional sheets e W tC&a " # Ye oji) tO A t 1 nm,1 t lbw a 6 , is Slat rwil 12 3P Fyl r , , p167foof x r'1 / lw i4 1fi I Ve i , ( . i Stir Th a t " l" 1 � C. '1 re aJr/n / li ; _ e 1277 . ff/ 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 1n the sum of$ L reel all 7iq-d/ca Guy it's 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;courf-approved guardian or guardian ad(item. I decla un er-pe Ity of perjury under the laws of the State of Washington that the foregoing Is true and correct. ) ' J - At r IN ign p Claimant Date Place signed(city and state) Reli:V7701- 117 ;')