1623 MCDOUGALL AVE 2022-05-26 - Laserfiche WebLink

, 11.If this claim involves a vehicle,accident/collision,provide your vehicle information: 4/17 Plate No. Make Model Year Drivers Name Drivers License No. / Vehicle Owner(s)(if different from driver) _r 7 Owner's Insurance Company Phone No. / Policy Na 12.Names,addresses and telephone numbers of all persons invol .ed in or witness to this incident: 13.Names,addresses and telephone numb fs of ail City of Everett employees having knowledge about this incident: /e / 14. Names, addresses dt3 telephone numbers of all Individuals not already identified in #12 and #13 above who have knowledge regarding the Habil' issues involved in this incident, or knowledge of the Claimant's resulting damages. Please include a brief description as to a nature and extent of each person's knowledge. Attach additional sheets if necessary. 15. Describe the cause of the injury a- damages. Explain the extent of property loss or medical, physical or mental injuries. Attach additional sheets if necessary. t/ete.k. ,.e.-0WIA1,3•17. . • t/ii-efl-7-2--- 16-7042/141/ gdedde.--4 "19:41e.,2/441 16.Has this incident been reported to law enforcement, fety or security personnel? If so,when and to whom? 17.Names,addresses and telephone nu rs of treating medical providers. Attach copies of all medical reports and billings. 18.Please attach documents that support the claim's allegations 19.1 claim damages from the City of Everett in the sum of$ 6 02 --6 ea 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 item. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. ifslt,1--1) --K(--e"/- /' — -- 6 /2 Si aturClaimant Date Place signed(city and state) R .07109