4917 SEAVIEW WAY 2022-05-31 - Laserfiche WebLink

r r • I 11.If this claim Involves a vehicle accident/collision,provide your vehicle information: Plate No. Make — Model Year Driver's Name Driver's License No, Vehicle Owners)or different from driver) _ Owner's Insurance Company Phone No. Policy No. -_ - 12.Names,addresses and telephone numbers of all persons involved in ora witness to this Incident: C� SvQ Cu phe 0 Z'7(7 Seav+4 C A-4i `1 v-e�e V- C1-jd-,S) 71-0 q7 .l — IMnr..v LJo t �.ey, �-•4'D) 14, l l s r gz GI eve --e if C 3'0 6 ) a_7d-— 7a-0 '1 Pew),s 6"t oe ti c,n 41 9 L---- cr,o.e,,J 1n/r,.1 E-;..e..e11 (4-0 6 a_ct_l_2 6 h y.- — 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this incident: 8r,ic , DO6IAry .CLie. tYsr?=Sad-8 --- _- 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. ff !ems F to U c Iv)CI 6) ea--0,of at+i a( ��t S P.wt O _. . t 4trc ._...a. GyeiLe.,4'e / Z >` c 0L_ 1st�.-S_; An 2 jrv, r� �jso c �oer cs_—rx i+r�Cd.v�J_.u`-.g..c_r..i-4`� _ /3eo k co, q e F.,h,, � 16.Has this Incident been reported to law enforcement,safety or security personnel? if so,when and to whom? 17.Names, telephone numbers of treating medicalproviders. Attach copies of all medical reports and billings. addresses and • 18.Please attach documents that support the claim's allegations. ' • , I 19.I claim damages from the City of Everett in the sum of$ 13-e t h,5 a� -' ^'`+�ad b,j 120 4-d P CN 1-r G t) CO- 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 litem. I declare and penalty of perjury under he laws of the State of Washington that the foregoing is true and correct ' ----- L3_f/3 -- A — Signatu a of .a' 1 nt Date Place signed(city and state) Rev.0710