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1~ ; <br /> STATEMENT OF SETTLEMENT OF LOSS <br /> Paid under Policy No. PB 123 <br /> Insured: City of Eu ene Account No.: 32981 <br /> Location: Eugene, OR Index No.: N/A <br /> Loss ID.: 87665 Date Paid: 27-APR-2009 <br /> Claim ID: 180339 Date Issued: 29-APR-2009 <br /> Report Date: 29-FEB-2009 Amount Paid: $41,425.00 <br /> Date of Loss: O1-JAN-2009 <br /> Location No.: MUL, <br /> Property Damage <br /> Building Damage (fire): $61,450.00 <br /> Debris Removal: $ 4,975.00 <br /> Less Deductible: $25.;000.00 <br /> Amount of Payment: $41;425.00 <br /> <br /> .PAY TO: City of Eugene <br /> Adjusted By: S. Laston <br /> State of <br /> County of ~ ~ ~ t, }SS The undersigned hereby certifies that it has <br /> . sustained loss and/or damage for which a claim has <br /> .been made under the insurance policy identified <br /> above, as shown in this Statement of Settlement of <br /> Loss. Endorsement of a check annexed.hereto or <br /> OR~I acceptance of an electronic transfer of funds is <br /> ~pa,~g0 acknowledged to be in final payment of said loss <br /> MI?C10lfE~SJIi~R~Oq and/or damage under said policy. This Statement of <br /> Settlement of Loss is incorporated into any additional <br /> settlements agreement separately executed. <br /> On this 9' day of ~ 20~ <br /> signer of the foregoing Statement of Date <br /> Settlement of Loss personally appeared before <br /> me and made oath that the same is true and <br /> correct to the best of his/her knowledge and <br /> belief and, if executed on behalf of a ~ ! z D ~ _ <br /> corporation, is within his/her powers to act for Name f Insured <br /> such corporation. . <br /> .Not y Public or J stice of Peace Signature and 'tle f Signer <br /> My commission Expires r, ~ 6~ <br /> ~ The signed Statement of Settlement of Loss will be <br /> kept on file by Factory Mutual Insurance Company <br /> statementsettlementofloss.dot rev.5Y08eeb <br /> <br />