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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 ' ._.a.,..�Rea <br /> Ri <br /> .,�.,c.�r.�..., .�..�...,...,�,..�.�....�...,.,�.e...,�.� _ '......���a�v....,,.�,,..�.�,. ����.. <br /> cu.s t3fc.),:kt-r <br /> in 7 <br /> (1 <br /> Policy Number 01 6 7 j 9 <br /> Type of Insurance 1 l <br /> Claim NumberPON 1--,-. 0 <br /> Settled Amount <br /> tf..., snow/few...el.* ,ot-N.* ...., lj 0 ki E--,.____ __„,,,, <br /> 1 Insurance Company Name € <br /> Policy Number <br /> I Type of Insurance <br /> t <br /> Claim Number <br /> I Settled Amount <br /> i Insurance Company Name <br /> i <br /> Policy Number g <br /> p <br /> Type of Insurance <br /> i <br /> Claim Number <br /> Settled Amount <br /> Insurance Company Name <br /> Policy Number <br /> K <br /> q Type of Insurance <br /> Claim Number l <br /> Settled Amount <br /> r EVERETT <br /> EL. WASifiNGTONI <br /> Everett CARES Small Business Grant Program l Round 3 ; page 9 <br />