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<br /> 11.If this claim irivrilves a Vehl404dentitoilision,provide your vehicle information: -..• • • • . ,,,-...,. -. --.,.,._-,- . -.......,
<br /> i . Plate No. Make Model
<br /> b.i.i License No. ' vihkiei)ire5).'irtiketehttiotii driver)
<br /> •
<br /> „, _.. ,.,„„„ • - _•-_. _ _ .._ ...... .... • ,. . ........._—:..._.• ,_ , . .. .
<br /> . .. • . • ---• . - -
<br /> OwnersZisurance Cohipqny , Phone Na PoIWNa, --
<br /> 11.Names,addresses atid telephope numbers of all persons involved in or witness to this Incident: .•
<br /> ;--i,..., -..••4 y .
<br /> (Art St • ' L - '
<br /> ----,,„ I .
<br /> 'DMA a ITAKiir -au- _0 402D.I .
<br /> . .. • ..
<br /> a i t....__ ...•
<br /> 13.NanieS,addresses and telephone numbers of all city'0 Dierett employees having knOwledge abciiitthis incideriti
<br /> Nei( 94Am 0.0 (eclat Si-- Veill* WA qVD (
<br /> I
<br /> _ _ ,_ ...,..,. __ ___ . .___ . . ,„ __ „.„,.._...
<br /> 1/4) . , .
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<br /> 14. Names,:addresses and telephone numbers of all indiViduals not already identified in -itla 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 /> deScepttrin as to the nature and extent of each persons knowledge. Attach additional sheets if necessary..
<br /> ,,. /. I' (A e.,'.7 41- • g-
<br /> : :„...,_ . . . _.,i......._ . ._,...
<br /> i t' ...bt .7 I• e t -• • —„ _ _ ..
<br /> • : -
<br /> is: 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 /> -. - .- - .- ._.• —
<br /> - CAAV.e.-c-6- 7--olithra - ,104.2-ksew- Li;i9e-::.,- V.r.A•Pab 9.,.:41`6 ..0 AA et •
<br /> _ ..... :L.:. .• . _ .„.,..... , . •
<br /> *.m,,--,.4 ,.. ....: ,:.:t.... , ,,... ,..:(.. ildr 1 WO 41P 4 - hur.., 1:- Ma-- Odifo CrilvL411,1 , ' '1,6
<br /> Ppa 4.-- g free, inh I 0 i- i,9_ ,-,- _...,Vie__, _.:
<br /> ilAt--W 1 Frcaaii4. - . / / laic e31-
<br /> (..me- - -, -- Dor goob er&/ oh__ ; ., otts _ . . ,.._, .
<br /> ..#e..._ ilk/47A,,._-7.., . -,,,e_, . _44.11,ichil,,,i; g _ „
<br /> 16.Has this incident been ported to law enforcement,safety Or security personnel? If so,when end to whom?
<br /> 11 A _
<br /> 11F . --. 'll-7
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<br /> 17.Names,addresses.and t lephOne numbers of treating medical providers. Attach:cciPles of all medical reports and billingS:,
<br /> 1\
<br /> -__ ... _ _ ,_... _ . „„ . . _. • :..., . ... ._ .. _ , ... • . , , , . - _
<br /> 18.Please attach documents'that support-the.clairds,allegations.
<br /> L .I claim damages from the qty.of Everett in the sum of$...1.7_13.7c). .. _ . •
<br /> This claim form must be signed by,either the Claimant or on behalf of the Claimant by an atterney-in-fact Wholiblds a Written power of
<br /> •
<br /> attorney for the Claimant,or by an attorney i at law admitted to practice in the State of Washington,or by a court-approved guardian or
<br /> guardian ad litem.
<br /> •
<br /> I declare unde2enalty o perjury;pnder,t4 laws of the State of Washington that the foregoing is true and correct:
<br /> ,•----
<br /> -.."--27-....
<br /> /.,3 0 3 _ EVerett VA
<br /> igiiature of Claimant Date, Place signed(city and state)
<br /> gpv..07/09
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