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• <br /> 11.If this claim Involves a vehicle accident/collision,provide your vehicle Information: fq 1.4 <br /> Plate No. • Make • Mode! Year <br /> Ontrer's Name Driver's license No. Vehicle Owner(s)(ifdiferent firm driver) <br /> Owner'sfnsurance Company Phone No. Policy No. 2 "lr <br /> Ct <br /> • 12.Names,addresses and telephone numbers of all persons involved in or witness to this Incident: b <br /> NUt111-` PK Qfue•,e,1 de-Mk-NA- E5V 1. t3 elu q.g?-4)e <br /> 6veielk, a► ' <br /> rib eS-3•G Traka <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 persons knowledge. Attach additional sheets if necessary. <br /> \,\,'4 nick,T a V.1 <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 /> •Cb l �� . 0 <br /> t5 <br /> 16.Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? 60 Ewe t <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. D,n�, <br /> 19.I claim damages from the City of Everett In the sum of$..., 13 1J''v�iU <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 /> • `N 1 ve6,froi3 0.\)-6\2-e-VC Nue' <br /> Signature of Claimant Date Place signed(city and state) <br /> •�+�.071Q9 <br /> • <br /> 11C9• <br /> 1, �� <br />