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11.If this claim involves a vehicle accident/collision,provide your vehicle information: <br /> P/ate No. Make Model Year <br /> Driver's Name Driver's License No, Vehicle Owner(s)(if different 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 /> 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 /> •- ',don as to nature and extent of each person's knowled•-, Attach additional sheets if necessar . <br /> - i:6 • f <br /> I. a i- is ;� * ' _ �i_ �4 ?oil <br /> (In .tow we. WO 1 4 0 Y" d tm vnd •fin\ w <br /> 15. Describe the cause of the injury or damages. Explain the extent of property loss or medical, physical or mental injuries. Attach <br /> a dit' nal sheets If necessary. <br /> S ti <br /> li } \ <br /> • i <br /> „uss „ <br /> 16 Ha this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? <br /> NI <br /> 17. Names,addresses and telephone numbers of treating medical providers. Attach copies f all medical reports and billings. <br /> . l ottq t i % fist-- r �2 1,a 1er-it- 1-M6k \Y(.6 0 <br /> 18.Please attach documents that support the claim's allegations. <br /> • <br /> 19.I claim damages from the City of Everett In the sum of$1-0 c 4) J'r #, <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 un er nalty of perjury under the laws of the State of Washington that"the foregoing is true and correct. <br /> 061 i Pi ti012 Ed-os114-1 .f+ . <br /> Sign re of Claimant Date Place signed cit- and state) <br /> Rev.071 <br /> r ki <br />