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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 from driver) <br /> Owner's Insurance Company Phone No. Policy No. <br /> 12.Names,addres and telephone number-of all persons involved In • witn•ss to this incident: n <br /> OKA ii Ali 5 'IL's' tea- CAN) <br /> fkiv0 itai 12 tvM tt ii�Xo^-1i 48qmsammusok tQs-tb i- bill <br /> 13.Names,add essgs and telephone numbers of all City of Everett employees having knowledge about this incident: <br /> l 1 . <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 brief. <br /> descrl�tion s to he nature and extent of each person's knowledge. Attach additional sheets if n cessary. <br /> e,4 Eh T: AR-6I R kik) YR--6PE2.,1E5 ( (-12-5 210 -9-1°1 <br /> 15. Describe the cause of t injury or damages. Explain the extent of property loss or medical, physical or mental injuries. Attach <br /> additional sets if necessa 1[v�{ 1, r I P t ! , <br /> t rt do_ i At 5 2A CK O V C'�V S o `) i`�anrtil6, <br /> .� t0G� our f2 (TL' fJ ('NP' i�kl4 .00h& 4kKm blk;ULrt F-Caa ft . <br /> ToiLf-Ti:$ i o���-t '�bL.F_, cJveS ro1Kfr-P5 isi-Ntlotp . k.5--C.. <br /> 16.H s this Incident been reported to law enforcement,safety or security personnel? If so,when and to whom? <br /> t gt-MI�V ► (3( rMu7CItvl ej j t) 1� Ti . .,I-`1"- <br /> t <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$ 7 3 D• . <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 iltem. <br /> I declare'under a of rjury n t laws the State of Washington that the foregoing is true and correct. <br /> , / 41q-/5 <br /> Signature of Claimant Date Place signed(city and state) <br /> Rev.07i09 <br />