1111 47TH ST SE 2022-05-31 - Laserfiche WebLink

!i .If this claim involves a vehicle accident/collision,provide your vehicle Information: Plate No. Make Model Year Drivers Name v Driver's License No. . Vehicle Owner(s)('If different from driver) • Owner's Insurance Company Phone No. Policy No. 12. Names,addresses` and telephone numbers of all persons involved in or witness to this incident: you.. ' rn 1boc c, tvexv--€ii-Y1 f- ottki6 e rv.e...ev LO ruQ.. 13. Names,addresses and telephone numbers of all City of Everett employees having knowledge about this inci ent: 1i (M-001 , oor .,6t) U , -r4- . c 6 P ,a.i( cy --. &A-- --Nr oc . 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. A C\C ` 0,r vv. 6,0 lit c f-A-1, r'n rYln n Go A-J 're_ to1,0.0 ; cinr,,Adisk i, tp r _make . `` ct, e. N`I ei_.j5j cort i .. i pi prom boa .'fir` 5 o-t1� ��.. . 6%..� a.vl'1-'. t'yt r e ( 'l_s_e/1 Mf h r�j��-vtlX / He /Alec h rNo. 0 0 el 4,t/I0 G-'1 pt�or�$ .is..Desctibe.tbe..catis.Q.Qf.the.Injury.or.damages,,.EXptain.the extent..of.,.property..loss„or..medical,.physical:or,.mental.injuries...:,Attach. . additional sheets if necessary. t ! . 's S Cck.CPe.4- aen..vt.a.$^c f:"u.4 Qr r3 r < c . YEA pe !60..k`n.roc-r"tCA cv4A.4- av ,. . a (,2..r/'ie4 a.ice Gh c-'r /0o 5 €r'vi.►r.. / wit/ I:V. 5; .5 cp.) cf nr a 1?obo )1 W)l/ fi eW pork my ea.rp f ca i', cA a-o r(r.ri r`l Any) 4i o h a e .._e 16. Has thiss�ingcident been reported to law enforcement,(safety or security personnel? If so,when and to whom?+1 C'o wil o v'i-. ve,51 vL/l ll iettmtr7 TYt(1 67'/0. e t/f iJ '-PP5 Ca-rpel de r ilOC I St'V 4.;i4t� or",n . 17. Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. i?0 ,t,j d.c• ( !SS`t9e.6 a c, nac,J 9 J' )4 ( a.m.itt ..S LP /l r1:f-la th•-` Vdl Yea Cu.rSQ t 1_54 c Q rat vtol-. a ifYi 18. Please attach documents that support the claim's allegations. �° c'Alt. . . 1.Qo`i50_vc t' f;q #-d 19. I claim damages from the City of Everett in the sum of$ I . 5..C5� eir- 3U. or !o Cau- 1 -10.60 No yyN cE--ck.1,r 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 under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. 6 6q .. I7- 0(3 Ev ..4 , CO4 - Signature o Claimant Li Date Place signed (city and state) Rev.07/09 �2 _/J _: