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11.If this claim involves a vehicle accident/collision,provide your vehicle information: <br /> Plate No. Make Model Year <br /> DnVer's Name Driver's License No. Vehicle Owners)(if different from driver) <br /> Owner'-Insurance Company Phone No. Policy 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 /> 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 /> 7' C t Sri c?f ?LAe, /+ c. $1i-/ 0,4s "/, t".), 1 n�'ELea'P.Irs <br /> • <br /> l'Z t w '1)i c'i - h-) q i h_ f i II Gip o rtu s thm 0 bar,/P/ W tr rr�-tCr; li,-a <br /> rv,�r-t� 7/,e I-�-�1 /-1 hr1 '& S r e (.,/s^'er 1 �/ C'i,t h e <br /> __II f � <br /> Ct)��f G l5 h'f ' r h* .fiP. altrrji e�� <br /> 16.Has this Incident been reported to law enforcement,safety or security personnel? If so,when and to whom? <br /> /V0 <br /> 17,Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. <br /> 18.Please attach documents that support the claim's allegations. <br /> 19.1 claim damages from the City of Everett in the sum of$a VC4% 62 Cl <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 /> eze //-/4.7/3 E,y,10 <br /> Signature of%2iA' <br /> Date Place signed(city and state) <br /> Rev.071a8 <br />