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i <br /> � <br /> i <br /> , <br /> 11.1f this clnim Im�olves a vehlde aaldent/co!lision,provlde your vehlde!nformation: ._. j <br /> /;'a:eNo. AL�i'e PF�dn' 1'ear <br /> Oiircr'sNanre --�� ���------- Onnr'sLlcarsr/lo. --- Vohr:lcO�+nci(sIQ/Ac7rnnf/iwndiivrQ <br /> Uwncr'tlnsuranreCompanY Pha:cAb.- --�--' lR7ryh'o. � � --- - --- -- <br /> 12.Names,addresses and lelephone numbers of all peaons Involved in or witne.s lo[hls IncidenL• <br /> �. _--- —_ �-- ---� -- - . . <br /> ------ - ------�- -- -- �- -�-- - - -�--- -.�_ _- . I <br /> 13.Namr.s,aJdresses and telephonc num�rs of all Ciry of EvereR employees having knowled9e about this Inddenl: j <br /> - - --- ---- - ---- -- -... - --------- -.__ i <br /> 14. Names, addresses and Ieicphonc numbcrs o(all Indlvldua'.s nut almatly Itlentilled In �12 and #13 above v:ho have knowleA9e <br /> rc9ardln9 lhe Ilablllry Iscues InvoMed in this Inddent, or knowled9c of the Clafmant's resulUn9 dama9es. Plcasc InduAr a bdef � <br /> desu�pUon��;to the nahue atn7 eRlent of eadi Per.;on s know!edge. Allach addi!lon.il sheeLs If neces;ary. <br /> i5. Descrlhe Uic causc af lhe InJury or Aamages. Euplaln Ine�ctent of properry loss or medlcai, physleil or menlal Injudes, Alrnrh <br /> additlonal shecL If nemssary. <br /> I' 7 /� / /` �/ � <br /> ..�1_OV1�1 � �)LZJC r litie.(` UI1...�JlL,SPuIPh� t-�nn�rd. 10,7�1 A �� c,T WRTf �`_ <br /> < I f r n J / y. r/� <br /> �J(.�IL��C�\ IA11�1 +�1_�'�u4:L' CuJQ.Ne �G' rrUfi!' , �,J0.�C1` A,4J?l_ $Vlk.l _U { l . <br /> � �-1 <br /> l��.,f l.un. _p. �_;1e7=1..p�/�1`.—a.�K�!�l<n u«_�1o.aLli,.i.c e�.. c�n fu„�_�.qa*wa-_ aJ e. �� <br /> --�-4i«r_u_! _(r�P[tti_2�.9 Go.»nlff�- --- . ..-�--- -'------ I <br /> 16.Has lhls Inddent bren�eperted to law enfu�cement,safety or;ecwtty personnel7 If w,when and to v;hom? <br /> _ . __.�._---_______.. . ._ ._. — __ _ . .. __ . . _ . <br /> 1 i,�umes,adAresses and tciephone numbers of trcating mcAlcal providers. Attazh roples oF all medlcal rcports and bllllnqs — I <br /> ______. .. -_—�_- i <br /> ifl.Plcase aU��di ducunicnLti U�al suppml lhe clalni s allc9aiions. � I <br /> 19. I clahn Jninayes 6om Ihe Gry of Cverett in the svm o(¢_. fd N�{��u�y.11_,-__L�C e d i�N$��c�T�o n , I <br /> Thls claim fonn musl be slyned by elthr.r the Ctalmant or on behall of�he Clalmanl by an altornr.y-Imfact who holds a wiilten pmv2r of i <br /> attomey for the Clolmant,or by an altomey at law admllted to pra:llce In the Slate of Vlashln9lon,or by a court-nppruviYf gue�dlan o� <br /> quordlan ad litem. <br /> I ded,m under penairy of perJury unAer the laws nf thc SWtc of Washln9ton that the foregoln9 Is true and mrtat. <br /> �,�;�,,,�.�����.�/� 9- ( 9- I 'i - -- <br /> Signaturo of Claimant A� Date Place stgned (dty and sta[c) <br /> ficv.07/08 <br /> �� � <br /> I <br /> ; �,\1 I <br /> !\!?; f �,� � <br /> , � <br />