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

Y 1 j 11.If this claim Involves a vehicle accident/collision, provide your vehicle information: F7 `2-['-'` C I€- Plate No. a e Model Year Driver's me Driver's Lice a Vehid nnf er(s)(if different from driver) Owner's Insurance ompany Phi N�a. Pali o. 12. Names,addresses and telephone numbers of ail persons involved in or witness to this incident: W $ (at k ck MSS liWe54-'�1A..e-A OtOmir_/S� /o �.tl'e�j�ii c' v etTrC -f�tnpaiS 1 t� ie C.13i'�`N, y,95 3Sct 7 • r f�a.ttihl �rA(��fY P7�L EPp A-f`�•LTV So*i,k'a �a 4.5-0/ I 7yt�aaPrz 5 // � CU) . Al Sa.t4 119-5-`�5 '-Sk? z-VW/ °glut 54,i'cW 0P /L 6D, 6iR t700,- 7CG' Was G2,,/1 f7`oe, i 13. Names,addresses and � telephone numbers of all City of Everett employees having knowledge about this Incident: �y i�tCl�t'i Gl' 7�J�` �J `/o� + f l U/tti�' �r tlt^rc 4fc�� 3 '74 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. ass . B t -- / Mit n't era J �s - - Ii I� - A tcrcrc ,. it.c-f eel mid at,/1�� e^�pt datti t.e Wl y VJo j 't'r't`e. a y'r��r� �' -S4( 51/14 v'i-1a�'f-•e�'. • 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. �,Y iM- r tt. f 17p S"'oaq"gvis�t "-;/ -v-e et9 60 - P.(" van i1,A1 1pi ty`c1,_144_ fA d 64 ki--c-/ v, C..-Y 100.4,._cp-oer i Lg a�/j�,cto n �f rG,� / l�oy/,/ -; .�� .,�.-J n c f ��/P. .,-�)� -[1^9/o/y�,/(y/f� )c/ rove Y /a 7 .5_ a cv?ct.cf -�rcrrvt a�rGl C�irf/L 1'tsC.�+CC.N'...c e.f-Ld (494-441 f l- �/ C7 (.�E'.Y 1U"� . „ .0-r-Ui-ed td (.A. -ke /-taI We it dt c'e 5' cz.-vu'I /447 �,c-.0,2 &/e Cl.yr 16. Has this Incident been reported to law enforcement,safety or security personnel? If so,when and to whom? yes f opv -c�°I o _1.1 i e_o 4.-rt e ( c�s�.t'E `flame bro`)-/h fr? 7ifo01 ito-s L�C,.gh Il Ga kt.repitectL ') 17. Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. c,:ao a mg C,1r AAA—evt a.--c . o1-Gt p(;cc \ e i Evl' c4cv,cilel y a C (6W0(,c . tv). In kajr n .. kiLwl. e v-e-vv Ma 18. Please attach documents that support the claim's allegations. 19. I claim damages from the City of Everett in the sum of$ . r q IO= aA 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. 1/'1/s) So d b 8q-.0I-X13 e Ji eog Signature Of Claimant Date Place signed (city and state) Rev.07f09 —�