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IF THIS CLAIM IS FOR AN AUTOMOBILE ACCIDENT, PLEASE PROVI7E THE FOLLOWING: <br />Driver's License No. <br />Vehicle Make: <br />Vehicle License Plate No. <br />Model: <br />Drivers Name: <br />Address: <br />Home Phone: Work Phone: <br />List the names and addresses of all passengers in the vehicle: <br />Name: <br />Address: <br />Phone No. <br />Owners Insurance Company: <br />Policy Number: <br />Name: <br />Address: <br />Phone No. <br />NOTARIZATION <br />Year. <br />I, SusRN C(%R�4hf , being first duly swom, depose and say that I am <br />the claimant above described; that I have read the abuve claim, know the contents thereof and <br />believe the same to be true. <br />�� �� <br />Signature of Claiman <br />SUBSCRIBED and SWORN to before me this ��h day of , 19�. <br />(Notary Seal) <br />��� <br />�'h'�aw�e �147uoz <br />Claim.gen.vns <br />l:/L <br />AR PUBLIC in �n F�r the Stat of Washington, <br />residing at � <br />My commission expires: A J%� ���o ��DD�� <br />