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11. if ffiIs dilm In� s vehide aaldent/callklon, provlde your vd�kk M�fwmaUon: �� <br />. /W(eNa Mmh M�Md Itw <br />AmerYAnvraeCbmm�Y . AkneAh Po�YCYNa --� <br />li. Namef�, ,ad'ndiesses and tekplrone numbers of �N permns Mwalved In a wkness m thk Inddent: <br />N fT - <br />13. Names, ad and ldephorK numbers af all Cay oi EYerdt. -e-m�ployees having know�edge aboul tMs hrcMeM: <br />/��� ��S.�zt,L — � /,/.� /��-�7 Shpr..�.soti. <br />14. Names, sddreues m0 tekphone numlxn o! eA Indvlduels not el�dy Mentkfed In I12 and f13 a6ove who have knowledge <br />rcgardl�9 the XadlNy kwes krvolued In tMs Incldent, a NnovAedge of Me CWment's rewKing damagrs. Pkase Include a Mkf <br />descriptlm u M Ihe nature and rxtmt af each permnY knowlndqe. A1nch addNbtrl eheeLs if necesAry. <br />� 7>. /<.. /�,' �/eS-3S�6—SGe.S _ e/s�,,. ..�. Pe-��� <br />15. DaMbe tM aux of Me InJury w d�m�ges• <br />addRlansl sheels If necas�ry. � <br />.->�.,� Q 4. <br />�.a- �ywr �� <br />�- <br />� L s r / �1 /C <br />-b/€G — �/�o�..d�.Or.�c✓ <br />F�laln the exlen[ of popeny loss or medlal, plpskal a menlel Imurles. Att�di <br />C�.- e.� -f� ���-S 'T��SL <br />AC M �t I�G 6�/J L <br />M <br />16. Has �lMjs Inclder�t 6een repalcd to law e�(araement, sately ar securlly perso�w/ieli If so, whm and to whan/i //�1 <br />/ 961C�f'�� �" ��^ 7�� i/�/G�.I�S 7`'.. NiSL � a��/GG� <br />17. Nama, addresses and tdephone num6ers of treetNp medkal provMers. Attach mpks of all medkel �eports and E1igs. <br />/t/D �/�- <br />18. Pkax amch documa�tt that wpport the dalmt aNcy�dans. � <br />l9.icFNmMmagesfromNepryofEvmettlnthewmds S�G£� 23 . <br />This ckkn (am must be signcd by dther the Oahnant a on 6ehatf o/ tha Culmant by m attarneydn-hR who holds a wAtten power of <br />altomey for ths qaNnant, or Ey an altaney at law admNO[d to p+ctlae In Me Shte d WasMngton, or by a muR-approv[d quarOpn or <br />guaNlen �d NOem. <br />I declare u�dcr pamly of pajury undcr the laws of Me Shh W Washl�ton Ihat tlie foteqoNp is hue and rorrect , <br />c-_.-7�'�` T� �� /�/- � � �c.t �. s I� !.✓� <br />S(gn�tu of ClalmaM / Da6e Piaca Nynsd �ciq and daEs) <br />Aw.siro. � ✓ffJ�,..-t <br />�•y� �n r io.��.` •-. <br />