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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 /> ._. <br /> Insurance Company Name <br /> Policy Number l <br /> ,,.. , <br /> Type of Insurance <br /> . <br /> (l I/ <br /> Claim Number <br /> ..,-, <br /> Settled Amount <br /> — it <br /> Insurance Company Name iY1 0 fk1 Lk‘t c k t,IA u en c t N.'3 i.,)1.5,..t f(A'a(.4.- t.... 0 <br /> Policy Number Ze p(i)(1)1 •I'V't 30it <br /> Type of Insurance Co AfurtAk,r 0,'(A\ GI tocie(Lk k, (...„,,-,kii I <br /> Claim Number 4. 4.,o 0000 itc, U <br /> VI Ci <br /> Settled Amount <br /> ) <br /> ' 1 0 33 8 .51- <br /> - <br /> Insurance Company Name fq a AsL, <br /> Policy Number <br /> Type of Insurance <br /> Claim Number <br /> i <br /> I Settled Amount <br /> Insurance Company Name \ <br /> 0 A.SL-1 <br /> Policy Number <br /> Type of Insurance <br /> Claim Number <br /> Settled Amount <br /> j,..........,_. <br /> EVERETT. WASHINGTON Everett CARES Small Business Grant Program Round 3 i page 9 <br />