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11.If this claim Involves a vehicle accident/collision,provide your vehicle Information: <br /> Plate No. Make Model Year <br /> IJ A <br /> • <br /> Driver's Name JJI Driver's License No. Vehicle Owneri's)(if different from doter) <br /> Owner's tnsmance Company Phone No. Policy No. <br /> 12.Names,addressees and telephone numbers of all persons involved in or witness <br /> �to this incident: <br /> 9 v� j <br /> I A i k.4 Vogel LLo z COO 7 4lnli-x r 9f.::tin 1A fii 1 1""' q '1— -] <br /> To s3°f spa,'At--ry p-stw e /$nl,> Lk . 9 —2%,, I'iy Z <br /> I/ <br /> 13.Names,add <br /> rr es and telephone numbers of ail City of Everett employees having knowledge about this Incident: I <br /> N , <br /> 1 <br /> 14.Names, addresses and telephone numbers of all individuals not already Identified In#12 and#13 above who have knowledge <br /> regarding the liability Issues Involved In this incident, or knowledge of the Claimant's resulting damages. Please include a brief <br /> description as to the nature and extent of each person's knowledge. Attach additional sheets if necessary, <br /> 'Nov r r7 44 40/.10a Dr47 L A 1TZ. Brow-,3l.fe7 4/ZS'-- c'to — S o 3 <br /> Ra,J . .S.t'o—ternt4 pLc..Fi+sKid 4IZS'—s7,—'72•$�f <br /> • <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 /> -56= ?AC-6- <br /> 16.Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? <br /> AID . <br /> 17.Names,addressils and telephone numbers of treating medical providers. Attach copies of all medical reports and billings, <br /> 1 /A- <br /> 18.Please attach documents that support the claim's allegations. <br /> 19.1 claim damages from the City of Everett in the sum of$ S is .3`f . <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!item. <br /> I declare under penalty of perjury under the laws of the State of Washington that the`foregoing is true and correct. <br /> ture of Jaffna t Date Place signed(city and State) <br /> Rev.07169 <br /> N:::2-e---- 1 <br />