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11.If this claim involves a vehicle accident/collision,provide your vehicle information: /t/ A.. <br /> Pia No. Make Model Year <br /> DNver'sName Ddver'sLicense No. Vehicle Owner(s)(If diA nt from driver) <br /> Owners Insurance Company Phone No. Policy No. <br /> 12.Names,addresses and telephone numbers of all persons involved in or witness to this incident: <br /> ! ` his i' 'vim '_ ► c <br /> ' <br /> R . d 1• :' J 40't,1 <br /> 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this Incident: <br /> • f <br /> ' ' i r,,,r•• i <br /> y. <br /> __. e.:.-�f j l� .**� y"'1 -�j/� /.+�`L i4;77""" <br /> 14. Names, addresses and telephone numbers of all Individ els not pI'(eady 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 persnn's knowledge. Attach additional sheets if necessary. <br /> e,ry1 . Yam• t.1 1�- rJ P--(a S f. Aieelk,iLL -- Lt1 2,,,5 CJ 0 ' <br /> ....- .2- --- 27 <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 /> t,•,sg z,)A Ay- -6 1-.) ¢ -- , ~6 ./ laare— Z.v kAy6A1 <br /> i 3 i�s�r.2 )&22 � V�Je <br /> 16.Has this incident been reported to law enfoKement,safety or security personnel? If so,when and to whom? <br /> )45/ e,.tai Til --7"- ___Cre-4s.---il '''61.."3•4&,-t---p-exf) t2p_A <br /> ;i)) •4,O/ bj, t• I I <br /> til ir. . <br /> 17.Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and bull gs. <br /> i 11 L, - ' <br /> ." y /. <br /> 18.Please attach documents that support the claim's allegations. A ZJ 4"f 7)G i).5 c)-o ' VIVI J )r <br /> 19.I claim damages from the Gty of Everett in the sum of$41C-Y J 7 C�f'" � <br /> • <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 iltem. <br /> I declare under penalty of perjury under the la s of the State o Washington that the foregoing is true and correct. <br /> 7L f <br /> Si feature of C la mant D to Place signed d state) <br /> Rev.07/09 <br /> (-07-W <br />