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'�+ - . 1 <br /> � SUPPLEMENTAL CLAIMS INFORMATION SHEET <br /> This sheet is to be completed by applicant who has bsen �vo(ved in any <br /> claim or suit during ihe past fne (5) years or who is aware of any incidents <br /> - which may�ive rtse to a claim. <br /> Comptete separais sheet for each ctaim or incident <br /> + •. Answer ali ques�ons futly. � . . <br /> � <br /> Principal ot firm must sign this sheet in addition to the apptica�on. <br /> 1. Name of F'um: City of Decat�s <br /> 2. Name of lndividuals of F'�m involved in Claim: City of Decat�a <br /> 3. Name of Claimant iist�_Shi�s� y�u <br /> ''� Date of AI(eged Error: 4/OS/87 �� <br /> 5. Oate Claim Made: 6/11/87 '�, <br /> 6. Name ot Insurer (if appficable): � <br /> 7. Present Status of Clairn: ❑ Pendin� � q�� � � g�;� <br /> 8. B Closed. Totaf loss Paid: 0 <br /> Total Expenses Paid: 0 <br /> 9. If Pendin�. Amount Asked in Summons: Excess cf $L5,000 <br /> Claimant's Settlement Cemand: n/a <br /> OefendenCs Settlement Otfer: n/a <br /> Insurers Loss Reserve: 0 <br /> : <br /> • Expenses Paid t� Date: 0 <br /> 10.Oetailed description oi ctaim and eveMs: <br /> Claim�t alleged breach of contract <br /> ...�..� <br />