722 LAUREL DR 2022-05-25 - Laserfiche WebLink

11,If this claim involves a vehicle accident/collision,provide your vehicle information: Plate No. Make Model Year Driver's Name Driver's License No. • Vehicle Owner(s)(if different from driver) Owner's Insurance Company Phone No. Policy No. 12.Names,addresses and telephone numbers of all persons involved In or witness to this incident: 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this incident: C%J4(-L D 1 r7 t ri'h �l,s. -�c�r. AND lz- /t+ 'f'C;E'7 DI t7 jdv di r'. 't1" 610114 *04 14. Names, addresses and telephone numbers of all individuals not already Identified in #12 and #13 above who have knowledge regarding the liability issues involved in this Incident, or knowledge of the Claimant's resulting damages. Please Include a brief description as to the nature and extent of each person's knowledge. Attach additional sheets If necessary. .....1..„Eiascribe the.ga,usg_a(-the..inju y or damages,_..Expl.ain_the_extent—r-.-of._.propert ,ioss,or..medlcai,,,physical_or,mental,in j.pries., Mask__ . additiona sTieets If necessary.-' :...- ...... . ..... : ...:.... :.:-.T.. r1.66pr U- I-6l>,1G1f- LX,UeL i, )-joIJ'5'E 1)Ji V) k l 4� �1V1 WA- kV� re.•f)M l ltt12 U J / � 4e > ' _oo�- 'vrLA psi .'c 1r it_ welt ),k 4 -rEr 1=1. =om,fripe . tiNAFAE. ' n (o'r r1= mJr i. muifivrAri t .r ) - el ruiwyog r�C`oU) re, r1-4 tailf 16. Has this incident been reported tt''o law enforcement,safety or securi personnel? If so,wheh and to whom?V1A .jl. araour 17. Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. 18, Please attach documents that support the claim's allegations, 19.I claim damages from the City of Everett In the sum of$ I I. 10 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 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 guardian ad litem, I,dec er pe t rtof pe?urly nder the laws of the State of Washington that the foregoing is true and correct, • 6 Sign Lure of iaiman Da e Place sig (city and sta ) Rev.07/09