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• <br /> 11. If this claim involves a vehicle accident/collision, provide your vehicle information: <br /> Plate No. Make Model Year <br /> Driver's Name Driver's License No. Vehicle Owner(s)(if different from driver) <br /> Owner's Insurance Company Phone No. Policy No. <br /> 12. Names, addresses d telephone numbers of all persons involved in or witness to this incident: <br /> L <br /> ins 4:-��. <br /> - - .e-r--�- �26�-- a q .-- 9'0A " <br /> yti ).311 VAG-- c 1 79x0 <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 person's knowledge. Attach additional sheets if necessary. <br /> • <br /> • <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 /> 0 0,9 0 '4-- R 1 JiteX tt)fr-e-t- IM-Q,i<14,10 ii-Afd <br /> O. Oft r �pro)e_#Y\e lit nj Pig i IV %pt‘ ,P1ooc1iç <br /> ,c� <br /> fit`, 9 e_ , " @ ` <br /> �ntl t�% • (`x7 �.y.••�-•1. ! >� u.4�� c�ju3�rA-1 h c7Xt'.,5� l'��1=' i '�lt`l�S <br /> tte..---t .+0`-he. IN 1./M4v 6 ,e4 <br /> 16..Has this incident been reported to law enforcement, safety or security personnel? If so,when and to whom? <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. <br /> 19.I claim damages from the City of Everett in the sum of$ tom 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 r dare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. <br /> �l_ ! /3 )1)-- <br /> ature of CI i t ate <br /> Place signed (city and state) <br /> Rev.07109 <br />