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11.If this claim Involves a vehicle accident/collision,provide your vehicle information: <br /> Plate No. Make Mode/ Year <br /> Driver's Name Driver's Licensee No. Vehicle Owner(s)(if different from driver) <br /> Owner's Insurance Company Phone No. Policy No. <br /> 12.Names,addresses and telephone numbers of all persons involved in or witness to this incident: <br /> f[t <br /> 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this incident: <br /> Jerry McManis 425-257-7000 Public Works <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 /> Sewer lines backed up from over capacity conditions flooding my finished basement. All <br /> rooms were affected. Large family room (tiled) and two carpeted bedrooms with walk in <br /> carpeted closet <br /> 16. Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? <br /> City of Everett Public Works Emergency 8/29/13 and Risk Management 8/30/13 <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,I claim damages from the City of Everett in the sum of$ TBD <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 /> • <br /> Sharon L. Gordo` / 8/30/13 Everett WA <br /> Signature of Claimant Date Place signed (city and state) <br /> Rev.07/09 <br />