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11. If this claim Involves a vehicle accident/collislon, provide your Vehicle information: <br />Plate No. Make Model Year <br />Drfmrs Name Driver's license No. Uehlcle Owners) (1fd/fferentfrom dr r) <br />Owner'slnsurance CompanyPhone No. Po/ky No. <br />12. Names, addresses and telephone numbers of all persons Involved In or witness to this incident: <br />o �/ A' C Ct ,41 :s / 1 't e- 5 a -- OC'% <br />13. Nam , addresses and telephone numbers of all City of Everett employees having knowledge about this incident: <br />14. Names addresses and telep <br />hone 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 />Ao e..ift,t 5M'3 Fri) 4., S ti`� � 3TO Ot.0 � <br />cv ,' 11I e- u -D & A4 A- ✓ i y a s - C-" s�) & io <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 if necess ry. <br />0*1 <br />0WAIWoo -7 hevX.I.— hVIJOL.'e',� <br />11 iv <br />,f <br />42 <br />16. Has this Incident been reported to law enforcement, safety or security personnel? If so, when and to whom? <br />0--; ru 5� = zq 113 <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 <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 />i declare under penidgof perjury under the laws of the State of Washington that the foregoing Is true and correct. <br />lam- _ 2 r <br />Mifnature of aimant a e Ptace signed (city_ <br />Rev. 07109 <br />