Laserfiche WebLink
; ' <br /> ILlflhisdaiminvoNesavNddeaucktent/cdlistan,pro��ldeyourvehkJeln�omiatbn: pafeA'o. - iJa1a faoCe7 Ynar <br /> Lnkii'Nenr � D;MrtUav�tehb. Vah7AdOnAn(rJ(r/dd/nmlhomdnYnJ <br /> O:�nNslnrwaur(bn1amY �SoneNa INkYNa. <br /> 12.IJames,�JJ�r..ses and lelephonc numbers of all persons invdved In or wlmess m thts InddenL � <br /> � l. 1 �- �cc� L�eLlylr��a�d �a5 �Fv:-7aa� <br /> _�__Lii� L� � ' `'� s ralte�--- e1�r1 a�_ <br /> 13.Names,aJdresvrs and lekphonc iwmbrr'a'all dly of Fverclt employees having knrnvlcdgc oboutlhB ixldent:— I <br /> 14. Nama,adJresses and le!ephone nu�i�bers of all 6v.lMduals not alrca�V IdenHO^_d In /112 and rf13 above who have knowledge <br /> ie9uding thc IIeMIXy I:s�.=s InvoWed In lhls IndAent, or knnwlcdge af the CJalmanC. resuttln� damaqes. Pleasc M�Qudc a bdef <br /> descdpUon as to Ihe natorc and�Ren!af each perwn's koo•xledgr., Altach addlUonal she^ts�f necessary. <br /> I5. Dcscribe Ihe cause of the InJury or damages. Explaln U�c extent of propeity loss or med'cnl, physiol or mental INuikc. Altach <br /> eAdltlona'sheets U necessary. <br /> �}v�u�l�.�e+� � e� c1�2•' ��ua�� s s � bac:�c� ,� <br /> ��c)� ��i,t.� ' � S r�in ev'an-F. �Inrm �^ <br /> �d ,�ai.J seuY.� � c . _dL .s "1 r''Vr K�_GaR-i ' <br /> -.� _v�t1S in ►at ipn v'e�,�. - Efln a� �i��CL��� <br /> 0 <br /> 14.Ilos lhls InUdenl bem mDmted to law enfarcement,safelyorSeanN PerSonnei7 lf so,whrn anA tu whcm? <br /> � ----- -------`------.. ..__....-_--_ <br /> U.Name: addres;�anJ lelephono numbers o`trealln9 m^dkal provWers. Attach mp'e,ot all ineJlcal R(�Ls nnd bi�in9s. <br /> _---�1-�---- --- ----- ._--- <br /> f 0.Please pl�laAi�(a�•;u�mrnL^Ihat support the dalm6 elkgnlhns.- -- <br /> ;9.1 clal�ldon�a�37rom Uu dry ot tYcrott In Uic sum or S 3�q� '�� � <br /> This clalm fonn must he stgncd by clfhcr thc palm�M or on b^_hnlf nt lhe Galmant by an altorneplm(ncjwlu Iwlds a wrlUcn power of <br /> altomey for Ihu CWimanl,or by an allnrney at law admllhed lo pradke In t�c SWte of WaslJn9tun,ur by a murtapproved gunrd:an or <br /> 9vardlan aJ Illem. ' <br /> I dttlarc undcr prna�ry��f DerJury urder Ihe Niws of Uie Slak W 1'lashington that Uie fnregdnp L^Uun a�d carctt. � <br /> ^ I <br /> �E.�'Fisl.��.--L-l��.t �� ! ��JI�� '`�Q4rY�t�V `�"IT � <br /> Sipnaturo of elalmant Datc Place slgned (ciry and stato) <br /> rte..orro� <br /> � , . <br /> � � ` � �.� <br /> � � <br />