3621 SHORE AVE 2022-05-31 - Laserfiche WebLink

11.If this daim Involves a vehicle accldent/collislon,provide your vehicle information: Plate No. Make Model Year ,v 4 Driver's Name Driver's License No. Vehicle Owner(s)(ifdilferentfrom driver) Owners Insurance Company Phone No. Palky No. 12.Names,addresses and telephone numbers of all persons involved In or witness to this Incidents 13,Names,addresses and telephone numbers of all City of Everett employees having knowledge about this lnddent: 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. ? M I Cit cinfira c ' .- 6..5- 0nre.Ik, -V-as Z-/V 3S'/ co+m >71 t.oIlcd ' cfN out $crAi tY (ba :cfis 1x1(; 1 j ( 105(1y Com,rOnni r �.►t� 1` hl�5 _ert l (Y1 dt'0C 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. . \00.4-)eMit.mot Qc*de, eta rinn't• a i1 heaU keiknetay> �'� lti �. 6l3 6-e_ &ew tk 1.t . is— ()Vex 44 o 1►i t , . - +-Cr 60)i% it e4 Y e r� t; e. a t. rj 14k tb N T rj s 3 . haA) 4abg. h10.C6urt Ci 40 cq \k D1 Br t)Y\( 1.-tpLu Ctnok 4,0Y th G( 0 ei Gin` YrM T1 I ,U e 16.Has this Incldeneen reported to law enforcement,safety or security personnel? If so,when and to whom? r1'b 17,Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. Nnttri 18.Please attach documents that support the claim's allegations. 19.I claim damages from the City of Everett In the sum of$ U"A a± . 7 v!1S ,ri flU!j 1A4(I S 4o 1 d 4.6 cc,,l Aixrt t t 1 Q t pp+��2 t" )�� h n , o i- v�S. ( e ra�'1-i a , This claim form must be signed by either the Claimant or on behalr of the Claimant by an a orney-rn-act who ho s 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 under penalty of perjury under the laws of the State of Washington that the foregoing Is true and correct. , 13 . (Ai Signature of Clai ant (/J( ' Date Place signed(city and state) Rev.07/09 V