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<br /> 11.If this claim inyolves a vehideactident/coliision provide your vehicle infOnnation:...— . . ...,...„..._.
<br /> • /4;ite./f/o. • Make ifiadii.
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<br /> 4 ig•licenA,No: vehdebiolerlintrititethtlibm drivel) ••'dimettiiisutancecogiany Phone No., - - - ' '-- ''' #01.10*; • - •
<br /> 12.Names,addresses and telephone numbers Oak persons Involved In or witness:to this incident: .:
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<br /> •. . ______ ___. . ..._. .. . . .. . .. . .,._ .
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<br /> •13.Names,addresses and telephone numbers of all Citybf a/bred employees having kribMedge abotitthiS incident
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<br /> : .. . .. ._ ... • ...• -:..... -....,..,
<br /> ____ ... _,.
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<br /> 14. Named,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 knowiedge. Attach additional sheets if necessary.
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<br /> 15 bescrlbe`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. r .
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<br /> t:9 ././)1,',1.. 014. I ti(AI; ...--tiv.-..„L •:, • s--- -/ , --1 V.A..-;,i.,..c...) • ,
<br /> f. ( • _•, i- i I / k:::' r' 1 .(1 er.'"r-'',,V"""'""•'''''''''''''.."•',$":" •,,'•':—-••`....'''•..":•,.:1,,
<br /> „ Li%•n t 14)::i':LL r.?,2,k .kA':..-5, '''' t''..'4.4 ''•:41•,—, •‘'',— s' i''
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<br /> 16.Has this incident been reported to law enforcement,safety or security personnel'? If so,when and to whom?
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<br /> 17.Names,addresses:and telephone numbers of treating medical proViders. Attach.COpies of-all medical reports and billingS.: r.
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<br /> .______.........._ _____-. . ... ..
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<br /> 48.Please attach documents that sUpport,the claimsallegations.
<br /> i .4. v . 15. •
<br /> 14.I claim dernages from the City of Everett:In the sum of$, ..l:,:.1,..‘_\....1!'.4.1.!'....°..!"-'''' r'`....,'F..' A; k, r.iii,,,,-;,. , .!
<br /> This claim form must be.signed byrelther the Claimant or on behalf of the Claimant by an.attorney-in-fatt who holds a Written power of
<br /> attorney for the Claimant,or by an attorney at Jaw admitted to practice in the State of Washington,or by a court approved guandian or
<br /> guardian ad litem.
<br /> I declare r penal of pe ury under the laws of the State of Washington that the-foregoing is true and eortect: .
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<br /> I) L-'u7-4.176# Will- •.
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<br /> $ignitarei - : &infant ip Mace signed(city ind state) ,
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<br /> 9.pv,..07109
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