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11,If this claim involves a vehicle accident/collision,provide your vehicle Information: <br /> Plate No. Make Model Year <br /> Driver's Name Driver's License No, Vehicle Owner(s)(If different(ram driver) <br /> Owner's Insurance 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. <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 iff necessary. <br /> ( t` �1L? `l. irt4 c' �k p:; `a •t 47,sr S' TZc c3F� iD+4LI <br /> • e.i.A:net l=c�fZ. r3 t7.sef ' 46A elt }y",a `� 4.f�IrYJ) i `l+'!il.`v Ys B.:lYr9 ''I <br /> D 0 <br /> y�r.�,t� � 0��2 �����- •f- --�:��t /'mot �c,,mtir_ <br /> 16.Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? <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$ jC; 7. V.)0 , <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 /> declare and r i` of perjury under the laws of the State of Washington that the foregoing is true and correct. <br /> .01 'E [ i Le� r it , <br /> ignature of Claimant Da Place signed(city and state) <br /> Rev.07/09 <br /> 1 <br />