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DocuSign Envelope ID:AC632329-6A2C-41CA-B8AA-8D15BC504B89 <br /> Please provide information regarding any insurance policies and information regarding claims filed and paid,if any,in the designated <br /> spaces below. If no claim was filed under an insurance policy listed below,fill in the applicable blank with"None." <br /> Insurance Company Name <br /> Policy Number <br /> Type of Insurance <br /> Claim Number <br /> Settled Amount <br /> Insurance Company Name <br /> Policy Number <br /> Type of Insurance <br /> Claim Number <br /> Settled Amount <br /> Insurance Company Name <br /> Policy Number <br /> Type of Insurance <br /> Claim Number <br /> Settled Amount <br /> _�..__ <br /> Insurance Company Name <br /> Policy Number <br /> Type of Insurance <br /> Claim Number <br /> Settled Amount <br /> 1 E V E R E T T Everett CARES Small Business Grant Program Round 3 page 9 <br /> WASHiNGTON <br />