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- 11.If this claim involves a vehicle accident/collision,provide your vehicle Information: Plate No. Make Mode/ rem- Driver's Name Dr/ver's Llceme No. Vehicle Owner(s)(if different from driver) Owner's Insurance Company Phone No. Polity No. 12.Names,addresses and telephone numbers of all persons involved In or witness to this incident: 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. �arescribe the cause of the injury or damages. Explain the extent of property loss or medical, physical or mental injuries. Attach a ditionai sheets If necessary. R v u —4kktSh - 'l cvr\ vt 45(MS,()No or\ n-t49c,t -)d4-A;24 ujGt S P)C. Yl r tr-e , tyvii . r triAs t CtG.2 S Q -\-p t,tr15 16.I-las 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. { - I 18,Please attach documents that support the claim's allegations. 19.1 claim damages from the City of Everett in the sum of 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. Signature of Claimant Date Place sign tcity and state) • Rov.07/09