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11.If this claim Involves a vehicle accident/collision,provide your vehicle information; _ <br /> Plate No, Make Model Veer <br /> Drivel's Halos Driver'sticensd No. Vehicle Owner(s)(If different from driver) <br /> Owner'slnsurance Company Phone No, Policy No, <br /> 12.Names,addresses and telephone numbers of all persons Involved in or witness to this Incident: <br /> 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this incident: <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 person's// knowledge, Attach additional sheets if necessary. r� <br /> E„ < CCS-Ie.t (Ce.�f/cr,J 'fC�ab-� I?2/ Ho/htoo(.< ,4-oe GJe,c6( 14/4 <br /> 1� /1 t . 1�A /! O. arr�0�__..( 20 a !-�3 sr (�'it 2)f7.) <br /> f-11'G�i� It, !)•' /o H W i�-r e/w</e. Pier. '_`qt�et'. ' -t°a Eueic roe—( LJ }+-+., �"R. A <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. I <br /> FluvCti`� u . CO) w ems Gus G4�s�.cac 1� . .rtteei tdc4 et'-,C( fur e. . <br /> e. Lit . . • <br /> Fo v��ore. / -c.io !3t ^fa i J f <br /> V e�Se CcsH c Gw/fc•-. ��...a..� p� <br /> Orl/�i�rf c,/ 206 -3 Sr:i 3 S-2 <br /> 16.Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? <br /> Na <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$ 36�'.d 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[item. <br /> • I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct, <br /> .�-' ,�-- C7o /S, zcl S i.ot•�c}S k to-I EtXN <br /> Signatu of claimant -Datee Place signed(city and state) <br /> Rev.07/05 <br /> 1 <br />