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4 <br /> i <br /> UST CLAIM APPLICATION <br /> INSTRUCTIONS FOR PAGE TEN <br /> , <br /> j XI. STATEMENTS <br /> Respond to the .,estions in this section to the best of you- knowledge. } <br /> i <br /> A. Check tl-e appropriate box to indicate if there is a insurance policy in affect on the site subject of this <br /> claim. <br /> ,IIS <br /> B. If the response to Item #A is "Yes", identify the name of the insurance carrier, the policy number, and <br /> ` the name and teleohone number of the claims agent most familiar with the site. <br /> li <br /> C. Read this statement carefully. Sign and date where indicated (original signature only). <br /> D. If you hale any knowledge of any other parties who may have incurred costs for or filed a claim with <br /> the UST C'eanuo Fund for cleanup of this site which is the!'subject of this claim, list the name, address <br /> and telephone number. <br /> E. Check the appropriate box. If you do have any k^owledgeof any controversy regarding this site, <br /> please gi%e a brief description. <br /> I <br /> I I <br /> } <br /> 'I <br /> II <br /> I � <br /> I <br /> �I y <br /> f � <br /> i <br /> i <br /> j <br /> I i <br /> I. <br /> 3 I <br /> � I <br /> I <br /> 'I <br /> I <br /> I <br /> i <br /> i <br />