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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 river U nse Vehicle Owner(s)(If different from 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 /> J3(fl CP('f-4-vn Ye-L Lv1t;S) sty 1i'etkQ-,) ; Ke U ' liacei <br /> -Hc>b Cd)- S (3 et r-e ss E j- ,g (1 <br /> U Je Evere_'i 3'r e a79 33R '5/ <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 if necessary. <br /> F)vo in el ha erne *v al u'l d,n <br /> Or`3 t,v j i ) CO.(P-64- .-4,rn a u r to _Xd <br /> 16.Has this Incident been reported to �w 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. - -1 <br /> 19.I claim damages from the City of Everett in the sum of$ / -11.1 b 34%1e'r m <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 litem. <br /> I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. <br /> Signature of Claimant Date Place signed(city and state) <br /> Rev.07109 <br />