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C 2.-' f <br /> 11.If this claim involves a vehicle accident/collision,provide your vehicle information: <br /> ___...._ __ Plate No. Make Model Year <br /> Driver's Name Driver's License No. Vehicle Owner(s)(if different from driver} <br /> Owners Insurance Company Phone No. Policy No. <br /> 12. Names,addresses and telephone numbers of all persons involved in or witness to this incident:At fi�r^^ i #'/mlSt w He <br /> t,uv °��'. <br /> .11t ! �t i ,...t .jrr rf 7��f�:�i," � t� �i,!t(\t j�l 'j j 1 �' ) )f .# _�j em pppp'S`Yf . s t <br /> f' ! ' �. r t f a+�t c. ''i.; l:Y i..p' bt 's t�r c.�F <br /> .. F i ,:,t - ri it ., y f 1 3 <br /> s i r o€ '\.,�; a ...:i., L/i h�-{b 3)�j! <br /> pq a �a ¢ 1 .� 1 :v' �� 4- 1�) <br /> 13.Names,addresses and telephone number/ets of all City of Everett employees having knowledge about this incident: <br /> J # a:Kt L e:tr 9'����',., 2�S'P'.,'�44�.:1 fib F' ae ! f. . ‘f 7 1 1 <br /> t. Tt. 1 , r c._ t„. F'_ fir. jf C:s.f1/ r`lt <br /> Y <br /> � {y �'i' 4��?\De ;+ � �.r{'! ,�� � �Z'+�}ti� J l,i �� i`i�L�l. �.:t i �k�.r�++ <br /> �.p�-R, 1 f,...g - `' t;:{ L�l d�:, ,v �Tt{f .,_ '�'i' l•^11/i'i G.-='�it el, � ! .,'•�/ " i4.s: <br /> r•.!J$.` i.-� fad f RFry ! {�'t.�� �!(( A a F��I :t..�'9:'F'�'t: '1'1 •{at.... k , oiler' r .C,� s �r '1 l ye <br /> •D W I e.. t. �� d t tf i S 1 {I r 'f .i,. 1 tt.� <br /> 14. Names, addresses and telephone numbers of all individtrais not already identified ins- <br /> regarding the liability issues Involved In this incident, or`•knowledge of the Claimant's resulting1zd above who have d ledge <br /> damages. Please Includeo a brief <br /> description as to the nature and extent of each person's knowledge. Attach additional sheets If necessary. <br /> 15. Describe the cause of the Injury or damages. Explain the extent of property loss or medical, physical or mental injuries. Attach <br /> additional sheets if necessary. <br /> w <br /> 16.Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? <br /> 17,Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. <br /> 18.Please attach documents that support the claim's allegations. <br /> 19.I claim damages from the City of Everett In the sum of$ ; '`10` ,,,+ 611:( C. <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 /> Signata F Claimant41.09 tc-_) 7i t,- i:<110 2. �.re . 1 y <br /> Rev.or�a� Date Place signed(city and state <br />