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

• 11. If this claim Involves a vehicle accident/collision,provide your vehicle information: Iv Plate No. Make Model Year Driver's Name 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 itness to this incident: • r) j v 1�-,A1 .� 1\1N �`'' b, S B��a5 as-0 s,tilA . gA,o3 `I25--aga-a931 elta, t3tW14 twA lit 3e. F,0Q.r b c&a ii3 J BkQ 0 = Son7e t 00 4•Z -3a°--7'e QD Everrd , t*A - i AZ A 13.Names,addresses and telephone numbers of all City of Everett employees having knowledge about this Incident: It e. 0u4'0 Lt2g`-- s -' `3 .`7t 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__p+'erson's knowledge. Attach additional sheets if necessary.-u /� 0 !1�3+1t Jial'Ir �C17�1 t}2. N p6�' ?sN�V1t�'ttSV\`� ��ec�rx�l) ^�-`� S. }i .yam •or al+ A kJkf x If 0 J.1 * tllc Ti0 5 VCR kkV(5 r-x 6.r" e5A `-R ct. 0046S `o ©ITV! 01- pinre-i 1 S 15. Describe the cause of the injury or damages. Explain.the extent,of property loss or medical, physical or mental injuries. A....ch • additional sheets if necessary. A \ 0- '` AO , A-lq 'ayl &Ialie) , 'DvaN . e &, ivv4 A- ii.OV AN, [fit►.` )v,Otal , , -.� 1�T (' (aNt,e- - n n1,,.etA)(10, c3Jflc ` lal� CkJv\L : st'?1)e_,--/ Cres- +INA 1,0(A-eikf` t)/0 " . ., I4 et ilE p, ! vis+ C • SAS • ' t.f IAA. _ �:w '1 it AAtAAI . , "AV .4 v tt OL,e.-J Y riy\ b c Rxi e, `- eve se,n cQ- bPj 5 ritt v(0 .V 16. Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whbfn?y NO-' `4 - ' -n1 \\ �c Qm(C). 17.Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. NO MO di e. Q- (5 S ve.5 io Y -10(5-(i - . 18.Please attach documents that support the claim's allegations. 19. I claim damages from the City of Everett in the sum of$ I)L O 3 �%— . 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. /699A4/ 12 //iffi 903// ��,e-e, , uoal S gnature of Claimant Date Place signed (city and state) ReV.07/09 1 '�—