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DocuSign Envelope ID:A9495BA0-3339-4A8E-9FBD-826BBF012FD3 <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 /> Insurance Company Name <br /> Policy Number <br /> Type of Insurance <br /> Claim Number <br /> Settled Amount <br /> `. W WASHINGTQN R ETT Everett CARES Small Business Grant Program Round 3 page 9 <br /> SH <br />