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11. if this claim Involves a vehicle accident/collision, provide your vehicle information: <br />P/Ne No, make Mode/ Year <br />Driver' Name DriversLIcense No. vehlde Oaner(s) (ifMarentAM driver) <br />owner'stnwmnce Company Phone No. Pol/cy No, <br />12. Names, addresses and telephone numbers of all persons involved in or witness to this incident: <br />13. Names, addresses and telephone numbers of all City of Everett employees having knowledge about this Incident: <br />/� ��}} f f, � <br />P , UAi,o C:6�, fir : il2 il_� ?G� %t G (liar% 4A'- /l r_ (yes � -?S7- � --M mt. ?13n1/..s' <br />� ..l - / � -7•�rl/1 rat 61r,� �„ act r� f,� a.[aa:M In - rr2�`'-rbn-. <br />14. Names, addresses and telephone numbers of ail individuals not already i`dlen hied in #12 and # 3 shave who have knowledge <br />regarding the liability issues involved in this Incident, or knowledge of the Clalmant's resulting damages. Please Include a brief <br />description as to the nature and extent of each person's knowledge. Attach additional sheets If <br />necessary. 1 <br />c'1- r"r "Gi �'nrl %"4. Sfvi S 260 -.5"Y %.z% �f ion& t/l.L.t YY..'F �tif1��. 1 <br />15, Describe the cause of the Injury or ama� Explain the extent of property loss or medical, physical or mental injuries. Attach <br />additional sheets if necessary. <br />16. Has this incident been reported to law enforcement, safety or security personnel? If so, when and to whom? <br />41 ., ... ,. _ A . , 1 �� +�, /9 l / - - t gas: ,-, r- <br />1Z Names, addresses and telephone numbers of treating medical provider's. 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 $, Jd-, ` <br />This claim form must be signed by either the Claimant or on behalf of the Claimant by an attornWri-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 penaltV—of-phnury under the laws of the State of Washington that the foregoing is true and correct. <br />of Clal-Maw ) /'/ Date Place signet'{city and <br />Rev. 07/09 <br />r <br />