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. .. <br /> ;.= • . .• . . <br /> 11.If this claim involves a velicleaCc*nifix?Ilision;prOde your vehicle infOrmation:. _,_ • ,,,....„,......--.. <br /> gale Ifro. Make ModelSf: .: <br /> :•. . <br /> , _.., . .. <br /> 01:kePS acenSe No. - <br /> vefilere'bRinerv-6).titeliffertntfratil driver) <br /> Owner's Insurance Company Phone NO. ' Policy-V.; .12.Names,addresses..and telephone numbers Of all persons-involved In or witness:to this Incident: . ... <br /> 47-__ A-rrAttias — A- . , ... <br /> 13.Names,addresses and telephone numbers of all city•of Everett employees having knOWledge.abOUtthit IndderiE <br /> 1,A, ekr.k t_64eC/_. P4ID Coti'l'att.:CYP-41.4)”°Vt 127.-?. ).1..R'71„. , ..... ,. <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 persons knowledge. Attacii additional sheets if necessary. <br /> TkA.P6.tiOttle 7_ , ee(Arr,.C-.13ZID 13.15r plisq-11c.,10,5eztilte_9,6F1,(0,8- <br /> . .:,., <br /> ( ) r o' —.ti,'1"ds'''''.---- vt'sC;;;;;(tho,•114r. Cal{4 0,A7 <br /> 6 CO-r6; •c-,.!.1..NY. ._... .iyel ,... <br /> .1.5; ' -ribe 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 /> • — _5g.....E ..A.TtAct-ta, _7_...g -- • ,..- <br /> .._. ... ._ , <br /> 16.Has this incident be n reported to law enforcement,safety Or secudty personnel? If'so,.when and to Whom? <br /> Ai fr e <br /> • . <br /> 17.Names,addresses:and telephOne numbers of treating medical providers. Attachicopies of medical reports and billings:, •,. <br /> A)11±:: -- . .,„. ..., . <br /> ..... <br /> . <br /> .._ ... • •,_ ._.. <br /> 18.Please attach documents:that support theclaim'sallegations. <br /> 10.I cfaim damages fronithe 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 whciholds a Written power of <br /> ;•. <br /> attorney for the Claimant,or by an attorneyatlaw admitted to practice in the State of Washington,or by a court-approVed guardian oli <br /> 84Pr.cliPa ad litem. <br /> I declare under perialtrof perjury:under the laws cif the-State of Washington that the foregoing istrue and correct <br /> gnaturesi am • fill-- <br /> bate <br /> Place signed(city and state) <br /> Rpv..o:nos Cd7-— <br /> .)---) <br /> 1 <br /> • 1 <br />