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IF THIS CLAIM IS FOR AN AUTOMOBILE ACCIDENT, PLEASE PROVIDE THE FOLLOWING: <br />Driver's License No. <br />Vehicle Make: <br />Drivers Name: <br />Address: <br />Home Phone: <br />Vehicle License Piate No. <br />Model: <br />Work Phone: <br />List the names and addresses of all passengers in the vehicle: <br />Name: <br />Address: <br />Phone No. <br />Owners Insurance Com;�any: <br />Policy Number: <br />Narne: <br />Address: <br />Phone No. <br />Year: <br />NOTARIZATION <br />�ores o � � e'e- <br />I, � elores m, , being first duly swom, depose and say that I am <br />the claimant bove desc.�ibed; that I have rea the above claim, know the conlents thereof and <br />believe the same to be lrue. <br />,�.o °'' -��� � �� <br />Signature Claimant <br />SUBSCRIBED en� ��ore me this � day of , 19�. <br />��,,.. �_ <br />(Notary Seal) <br />cm� � �. <br />NOiAqy 9Nl y <br />a F;iri��c <br />'�j, io.r.,.,00a �p2 <br />��F WASH��/ <br />C�' � <br />NOT RY UB { in and for t e State of Washington, <br />residing at � - . <br />My commission expires: ��-�,t,�b �OQ.�' <br />