4724 GLENHAVEN DR 2022-05-24 - Laserfiche WebLink

T 11,If this daim Involves a vehicle accident/collision,provide your vehicle Information::.....- . . Plate No. Make Mode! •" Year. , 1 Driver's Name Ddbers ticense No. Veli cie? vner(sj(Ifdlfeientfnm drive') Owner's Insurance Company Phone No. Polley No. 12.Names,addresses and telephone numbers of all persons involved In or witness to this incident: 4/1da 5/GICtla t 7 cf . G( o Pt e t Otr. / es.e#/ fA.4 cie 3 0.0 -2 /9. - SS9 13,Names,addresses and telephone numbers of all City of Everett employees having knowledge about this Incident: 4 6tfek- 19attwef e 1 3,boo Cedare_ SlYzPd f !l1(:c f 1 g.?o/ if .D-S l .D5 731 . 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. i'2t2 .Si • vici .. �1us�ari d -- Ssame .,�o(d .ss, >'u c� 1f�S -a h a��X lire e. lt.�r, u cry I Luc-('w l el a o it ...a c(- i q S o " �elfeyrs Iet�,,,, �� o yi s ge, ‘► l;an (11?5) 6 3 - Z d-ei/ .awl SeJi6zl/ 1 5 " . 15. Describe the cause of"the injury or damages. Explain the extent of property loss or medical, physical or mental injurie�.' tfach^1 7O additional sheets if necessary. tleauil 0.ct1n.• d 8id41/a013. .cuctced. GVu(-e/z.at-,d eleionas.�::..(nnrrn...:fhe.. s- ee4 -?,foyt't e dOWil .P1/11. t(2r .r C,(cc I-hie c.a-a.lei .. a-F • 6 t ij 1..k . . r"v-e z�y r . (a° .. -Pond. e 1 iid., ku d YLrzw . aka be 4s + . , ea ., ,U ed 1r12C(t2 ... .. .. d ►w-y ive,(.,, pots / .oueVL ,c2,trewt:Ly ft(J, 16.Has this incident been reported o law enforce ent�safe or sec rely ersonnel? If so,when and to whom? ' 5 /, r�` eq3 e,�1 p r c�or)^ S r 3�a Pa .� P 1 J i Wo,21 .r (Y+'t ! !Do,,�/1 n ] t5 Jt're ii' I Yil / f yt q(1 .3linan 3v 17.Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports arid billings. 18.Please attach documents that support the claim's allegations, / 19.I claim damages from the City of Everett in the sum of$. 7; tie ..d (`/Jed This claim form must be signed by either the Claimant or on behalf of the Claimant by an attorney-in-fact who hbids 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!item. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct i. r�Veaell, WA Signatu " of Claimant (i //3. te Place signed(city and state) Rev.oiia .