1902 LOMBARD AVE 2022-05-25 - Laserfiche WebLink

11.If this claim involves a vehicle accident/collision,provide your vehicle information: N/4- P/ate No. Make Model Year N14- 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: f im Stria, L-0mba- &veret 2C '- 234- 53t 2 , —Hc burg-he,e-tnra. 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this incident: ck yl 'J 30 1 Ap ed L y S' a n #-2 ttslun j Yr- fa/U ar ca, /Ite, t was 541rei1 Public Works bept Lcffer hours .er'iergency rut.mh,er. 1 Gal a/td asri i2 - StU who I spDke_ with 4h d-- vl l-h,f-b-tki- fie he S/ r{ed a_reperf 1 called a-aalj d/14 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. Annieu.¢.. ne I'W(o Lombard Ike., 3O-320-2574 -also experien.cad Ica i sRw *✓� jar prviv i t 92a 1`N-h St') �425-1a�(I-$373 helped ne►nov� n u> vg$e1-h i(ll C.�1� l fQ� TZ7T 15. Describe the cause of the injury or damages. Explain the extent of property loss or medical, physical or mental injuries. Attach additional sheets if necessary. 62� fia-cded ofc-tha ram on BA9Ji3..�/4 4a; £ red-m. t a/ and &Q. e• ime up 1 zm .i'n-j1G ,' �hbwe'r' au1z . L� the *iL4-(leav s aid M•dY-) 0 r wirier-tine LJ 1}i c and G/ � �bm fl a �En Clad �x�p pump, +1.e .S tb Iwo reel- of wafer- was down `fhra/4e. Pre had ID reola_uz troy wrier hnJ-e�my /nac. k not wartcFn yl ary Wag nCar bQ. refilved FV-Plrt,cadG_ IT/S0, fr- will need fn b.e 16. Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? —See ailachpzi frreo2.ept,) PtSkic Works on 6130. I do nod have ruLemes of who t spoke. ft�. 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$ C1 be-d¢1 ynnte1J 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 declare under penalty of perjury under the laws of the State of Washington that the foregoing Is true and correct. • 7/2//3 151erelt Signature of Claimant Date Place signed (city and state) Rev.07109