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ClTY USE UNLY CiIY UF FVEIiFIi , L11 "-" "'•`• lv I-� _� <br />� ' Uistribution to: <br />Nttachments � Scott Wetzel <br />Police ReporL �__ Claim for Dai�iages Form Risk Manager � <br />Collision Report r �k.�l.�.� `91 — Dept. Code !1 <br />Other ,_, � Dept Head's Name <br />Dept Head's PH____, <br />, who resides <br />Please take notice, that �7,�.o_r_aTG �' �+ M K�f �e ep one ll� �-�–/3 o a. � <br />et M � and wlio for six months prior to the occurrenoe <br />wor one il T— cleims damages of and from the <br />resided at � <br />City of Everet n e sum of ar s ng qut of the 'Follod,�g L ircumsUanCeu r, <br />llsted below: U U (T J <br />g NOV ^ � �:lu.r? <br />DNY/TIP�E OF OCCURRENCE: <br />LOCATION OF OCCURRENCE: .2 /G Nl a. cI i s o n S t –y-jj�llii0i91B}I S UttICB <br />DESCRIPTION: <br />1. Des�ribe occurrence explaininq the nature of the defects or nets <br />of negligence causing damages. R���EZV�I� <br />2. <br />3 <br />Provide itemized listlny oP all expenses, injuries, and lossesNOV 2 4 1986 <br />and attecli copies oF esLlniel:e or bills. <br />yC�7'Y CLERK <br />Provide e list oP witnessPs Cu I:he occurtence includiny nawe � <br />addresses, and phone num�ers. <br />@, � r e a. d. y <br />� - Sk«t� <br />Additional InFormation Re ui�ed for RU'IUMUBILE CLAIMS ONLY . <br />License Plate tJo:, <br />Type Auto: <br />(year <br />DRIVER: <br />Fddtess <br />Phone ll:_ <br />Driver License No. <br />Rddress: <br />Phone ll <br />PASSENGERS: •: <br />Name: <br />Name: '— <br />Address: Rddress <br />OYIIJERS Insurance Co. & Policy No. <br />I� �� pA�� , 6eing first duly sworn, depose and say <br />that I am 'e c�ment e vve described, that I have read the above cleim, know the <br />contents thereof and believe the same to be true. <br />SUBSCRIBED and SWURN io before me this <br />� day of � � � _� 19� <br />ra <br />� <br />