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iY <br /> %:+.�?' ::��:%'::%+`;`:y3f:%� �': ti::::T. '�<:��::' ::3:�::' ':: �?c2 :'�'#:'��':�:� :�<:':�:r`::::::5;:: ::;�:''�::`:'� �::5?:f•':�:� :�::::�? :� :#:'�:<iG�+%i: :' i <br /> i <br /> A. IS THERE AN INSURANCE POLICY IN AFFECT ON THIS SITE? L- YES j NO <br /> S. IF YES.IDENTIFY THE NAME OF THE INSURANCE CARRIER,POLICY NUMBER,AND THE CLAIMS AGENT FAMILIAR WITH THIS SITE: <br /> L� <br /> Insurance Carrier I Policy Number <br /> Claims Agent 1 i Telephone <br /> i <br /> C. I hereby give my authorization to the UST Cleanup Fund toy contact and obtain any information <br /> deemed necessary from the above—named Insurance Carver for the purpose of eligibility <br /> determination regarding this claim. <br /> CLAIMANTS SIGNATURE j DATE 4 <br /> I <br /> i <br /> PRINT NAME <br /> a <br /> u <br /> i D. IDENTIFY OTHER PERSON(S)WHO MAY HAVE INCURRED COSTS OR WHO MAY HAVE FILED A CLAIM AGAINST THE UST CLEANUP <br /> FUND FOR THE SITE WHICH IS THE SUBJECT OF THIS CLAIM: ! i <br /> 1 II i <br /> Telephone <br /> Address <br /> t <br /> Name <br />� VIII j <br /> 1 Address City,State,Zip Code ' <br /> i <br /> f <br />{ Name Telephone <br /> Address City,State,Zip Code j <br /> 'I I <br /> II t <br /> E. DO YOU HAVE ANY KNOWLEDGE OF ANY LITIGATION <br /> i REGARDING THE SITE THAT IS THE SUBJECT OF THIS CLAIM? I NO YES — Please Explain: <br /> I <br /> f <br /> III <br /> I � <br /> L I <br /> i <br /> Ali <br /> (REVISED 1/84) (SEE FACING PAGE FOR INSTRUCTIONS) PAGE 10 <br />