414 ROCKEFELLER AVE 2022-05-26 - Laserfiche WebLink

11.If this claim involves a vehicle acckdenr/collision,provide your vehicle information: N/A Plate No, Make Model Year (PcDriver's Name Drivers License No. Vehicle Owner(s)(If different from driver) Owner's Insurance Phone No, Policy No. 12.Names,addresses and telephone numbers of all persons involved in or witness to this incident: CLALIcE t-ea Po i C ( 33(0- 3gA.9-ei 3 3 .PO6 -5'30 -/ 7/.6 e API L.AL.0001. 419 e-o EFE LCe- „_ e yr 2ed U/ 1) 5 5-30- 7S' `// 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this Incident; 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. 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. • FG.O0060 6fis E.14,7air Conn} Ay., F.om ei t y s i afrvt o %i nJS o v eLF-1.f:,J Ey.o ., ONE FOQT U A_ ris eig 6 O F W A r L(e,-fL Y, /Al m y& I6LAC K i N Z E a i NT A k-40 14r"7• (YIE rR L 4- PH y i c:1,i-L 67I f 64u did yPA2 OL.A (ite 4-to/zie C1iJiue 16.Has this Incident been reported to law enforcement,safety or security personnel? If so,when and to whom? 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, f 19.I claim damages from the City of Everett in the sum of$ Vim 401,00 A-T.TI I L°S "r1 4'1'G v 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 lltem. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.0E_ 2 'z ?41m 6-,`��,�-- ( 9 i � ).,� Ev r-7; WA Signature of Cla ant Date Place signed(city and state) Rev.07/09 )\\