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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."
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<br /> Insurance Company Name �
<br /> Policy Number /1� �- Z�1- �6�.6-3/--rs3 o
<br /> Type of Insurance 1C)rpp -� 1
<br /> Claim Number
<br /> 111on e.
<br /> Settled Amount ky?t
<br /> Insurance Company Name ,6eri /littitica./
<br /> Policy Number7:6 f 85.3 --p�p
<br /> Type of Insurance Ala41, r
<br /> Claim Number /J/`an c
<br /> Settled Amount jY aW� l
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<br /> �✓..,...:.o,................µm _ .._µ..�F�.�.u..,w_.,..�..�.,.�.,....�,a.,.F��...�..�...a...�...�..�:�,..,�w�..r..�.�.�_.....A._.,.�.,,.,�r..w.��.,�.�..:t,..�.......�.�,_.a..�,�..,�.�._.��.���,.�.�,w:...�.w�._..�..o-�...,s,..,,..,....�..,.�,.�....�.�..�.h..�.M:.,.�..._.:.�.,�....�...�
<br /> insurance Company Name
<br /> Policy Number
<br /> Type of Insurance
<br /> Claim Number
<br /> Settled Amount
<br /> ....,...::..�_....�.�.,.r..Y..�.�,..�,_....�.�.w�..w...y.�.,. ....n�„w...�..�...w_..m.��...��_�.��_....,.,.�u:._�.,..,�u��,...�....._.�...,�r�..._....,... Aw_.�...�...�:�.�.b.�...,.�:.._...�b.�..�._ �.�..,,,..r..,...�..��.�.�..�,�,�,...�..��.,..,,_Y...d._�
<br /> insurance Company Name
<br /> Policy Number
<br /> Type of Insurance
<br /> Claim Number
<br /> Settled Amount
<br /> E V E R E T T Everett CARES Small Business Grant Program ' Round 3 page 9
<br /> WASHINGTON
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