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., - � ► <br /> SUPPLEMENTAL CLA{MS tNFORMATION SHEET <br /> This sheet is to be compleied by appticant who has been involved in any <br /> claim or suit during the past five (5) yeacs or who is aware of any incidents <br /> - which may give rise to a cfaim. <br /> iComplete separate sheei for each claim or incident <br />� '. Answer alt questions fuily. � . . <br />� <br /> Principat of firm must sign this shest in addiGon to the apptication. <br /> 1. Name of Frtn: Ci of Decat�s <br /> t9 <br /> 2 Name ct Individuals of Frm tmrolved in Cfaim: Ci of Decatzxr <br /> t9 <br /> 3. Name of Claiman� Hsc�n- ' Wu <br /> 5'h�.an� <br /> '"�' Date of Atteged Esror: 4/05/87 <br /> 5. Date Ctaim Made: 6/Il/87 <br />' 6. Name of Insurer (if appticabte): <br /> 7. Present Status of C�aim: ❑ Pending � C�o� a In Suit <br /> 8. if Ciosed. Tota! Loss Paid: 0 , <br /> Total Ezpenses Paid: 0 <br /> 9. if Pending. Amount Asked in Summons: Excess of $I5,000 � <br /> Ctaimani's Set�ement Demand: nIa � <br /> DefendenYs SetUemeni Offer: n/a ' <br /> tnsurer's loss Reserve: 0 � <br /> � <br /> • Expenses Paid to Date: 0 ' <br /> t 0.Detaited descrip�on of c:aim and events; 3 <br /> Claimant alleged breach of con�act <br /> �M.z <br />