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• <br /> 11. If this claim involves a vehicle accident/collision,provide your vehicle information: <br /> P/ate No. Make Model Year <br /> Drivers Name Drivers License No, Vehicle Owner(s)(if different from driver) <br /> Owners Insurance Company Phone No. Policy No, <br /> 12. Names, addresses and telephone numbers of all persons involved in or witness to this incident: <br /> 6 v'i Mo"-fJGrne/ny -' L'76 7M `71411 <br /> 5*-)ay. 7364oy\. �S2V1 1114 <br /> A)&' A.y lce4 )er— — L�2. 'J `71 <br /> 13. Names,addresses and telephone numbers of all City of Everett employees having knowledge about this incident: <br /> CVzk • 61? �.c"F6-117e'v Wei -ir— d fqrs- +en-/- 1)--kS ` 3OO <br /> • <br /> 14. Names, addresses and telephone numbers of all individuals not already identified in #12 and #13 above who have knowledge <br /> regarding the liability issues involved in this incident, or knowledge of the Claimant's resulting damages. Please include a brief <br /> description as to the nature and extent of each <br /> l�perrson's knowledge. Attach additional sheets if necessary. <br /> ikir 9-2-6 —11.010 C.99-1 <br /> 15. Describe the cause of the injury or damages. Explain the extent of property loss or medical, physical or mental injuries. Attach <br /> additional sheets if necessary. <br /> Olt` 8l'Znjt3 Anti 9/5/8 5ev^ '►' ►r"l t3 Q),'�2t 46 `�- a c r�(1 j' CU.vl�'v� <br /> 16. Has this incident been reported to law enforcement,safety or security personnel? If so,when and to whom? <br /> 46, L& C4 ;1'• Oc <br /> 17. Names,addresses and telephone numbers of treating medical providers. Attach copies of all medical reports and billings. <br /> • <br /> 18. Please attach documents that support the claim's allegations. <br /> 19.Lclaim damages from the City of Everett in the sum of$ as.LI 1 <br /> This claim form must be signed by either the Claimant or on behalf of the Claimant by an attorney-In-fact who holds.a written power of <br /> attorney for the Claimant,or by an attorney at law admitted to practice in the State of Washington,or by a court-approved guardian or <br /> guardian ad litem. <br /> I declare under penalty o perjury under the laws of the State of Washington that the foregoing Is true and correct. <br /> 6/4.4 <br /> Sig tur of Claimant Date Place signed(city and state) <br /> Rev.07/09 <br />