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2005/2006 Renewal application for LMCIT Insurance
,From:Kate Tiboina At:Landmark Insurance Services FaxID:651-464-7596 To:Eric Johnson.City Admin. Date:3/82006 09:23 AM Paae: 1 of 6 Phone: (651) 464-3333 ext. 209 Fax: (651) 464-7596 io Fax From: Kate Tipping To: Eric Johnson, City Admin. Pages: 6 Fax: (651) 439-0574 Date: 3/8/2006 09:23:18 AM Phone: (651) 439-4439 Subject: No-Fault Sewer memo Message: • From:Kate Tipping At:Landmark Insurance Services FaxID:651-464-7596 To:Eric Johnson,City Admin. Date:3/8/2006 09:23 AM Page:2 of 6 OCT-17-2005 10:59 LEAGUE OF MN CITIES 6512811298 P.01 • League of Minnesota Cities insurance rud 145 UniversityAvenue West,St.Paul,MN 55103-2044 (651)281-1200• (800)925-1122 PromatimejMinmwacet: Fax:(651)281-1298•TDD;(651)2811250 www.lmnc.org LMCIT NO-FAULT SEWER BACK-UP COVERAGE Date: October 17,2005 To: Landmark Ins Services-Kate Tipping Fax: 651-464.7596 Pages: 5 TRINE' From: Patricia Mingee CPCU, CIC AN 1 "06 LMCIT Underwriting J. 851-215-40811800-925.1122 ext 4081 14SURo pmingee@lmnc.org GOn►EE T4=Co 1 sA t 1 • Re: City of Oak Park Heights oTKEFq I COVERAGE IS NOT BOUND Hi Kate I have reviewed the sewer collection system maintenance standards adopted by the city council. This document does confirm that the city is committed to formalizing and improving their inspection and maintenance program. I am sorry to advise that their program does not meet the minimum underwriting criteria as outlined on the attached 11/2812000 Memorandum. The city does not qualify for the optional No- Fault Sewer Back-Up Coverage. Areas that would need to be addressed are as follows: • > Establishing a 3 year cleaning rotation for all clay lines A Providing a back up power source at each of the city's lift stations i! Maintaining proper records which reflect inspections, maintenance and handling of problem areas. If the City would like to reapply for this optional coverage at a later date,feel free to contact me directly. We are closing our file at this time. AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER From:Kate Tjpping At:Landmark Insurance Services FaxID:651-464-7596 To:Eric Johnson,City Admin. Date:3/8/2006 09:23 AM Page:3 of 6 OCT-17-2005 10:59 LEAGUE OF MN CITIES 6512811298 P.02 r'----,_„„ 1.41\14C LMCIT Risk Management Information L.,,n„p./Minn t ,Cities 145 University Avenue West,St.Paul,MN 55103-2044 Odes „,rx..�rmY Phone: (651)281-1200•(800)925-1122 Fax: (651)z81-1298 •TDD(651)2814290 www.lntcit.Imnc.org OPTIONAL "NO-FAULT” SEWER BACK-UP COVERAGE offers ro /casual member cities"no-fault"sewer back-up coverage. This new LMGiT of p p y ty optional coverage will reimburse a property owner for up to$10,000 of clean-up costs and damages caused by a sewer back-up, irrespective of whether the city was negligent or legally liable for those damages. This new coverage option is intended to do several things: . To reduce health hazards by encouraging property owners to get back-ups cleaned up as quickly as possible. • . To reduce the frequency and severity of sewer hack-up lawsuits.I.e,,property owners may be less inclined to sue if they receive conciliatory treatment at the time of the back-up. . To give cities a way to address the sticky political problems that can arisc when a property owner learns that the city and LMCIT won't reimburse him for his sewer back-up damages because the city wasn't negligent and is therefor not legally liable. Many cities and their citizens may find this new coverage option to be a helpful tool. However, it's also important to realize that it's not a complete solution to sewer back-up problems,and that not every possible back-up will be covered. What sewer back-ups would be covered by the new coverage? The no-fault coverage would reimburse the property owner for sewer back-up damages, regardless of whether the city was Legally liable,if the following conditions are met: • The back-up must have resulted from a condition in the city's sewer system or linos.A back- , up caused by a clog or other problem in the property owner's own line would not be covered- . It's not one of the situations that's specifically excluded in the coverage. • The coverage limit has not been exceeded. • From:Kate Tipping At:Landmark Insurance Services Fax1D:651-464-7596 To:Eric Johnson,City Admin. Date:3/8/2006 09:23 AM Page:4 of 6 OCT-17-2005 10:59 LEAGUE OF MN CITIES 6512811296 P.03 • Which situations are excluded? The no-fault coverage will not apply in several"catastrophic"type situations. Specifically,these are: • Any weather-related or other event for which FEMA assistance is available; • Any interruption in the electric power supply to the city's sewer system or to any city sewer lift station which continues for more than 72 hours;or • Rainfall or precipitation that exceeds the amount determined by the National Weather Service to constitute a 100-year storm event. What costs would be covered? The no-fault sewer back-up coverage would reimburse the property owner for the cost of cleaning up the back-up,and for any damage to the property,up to the coverage limit. For purposes of the city's deductibles,claims under the no-fault coverage are treated as liability claims, so the same per-occurrence and/or annual deductibles will apply. However,there are certain costs that would not be reimbursed under the no-fault coverage: • . Any costs which have been or are eligible to be covered under the property owner's own homeowner's or other property insurance;and • Any costs that would be eligible to be reimbursed under an N HHP flood insurance policy, whether or not the property owner actually has NFlP coverage. What is the coverage limit? The limit is S 10,000 per building per year. For purposes of the limit,a structure or group of structures that is served by a single connection to the city's sewer system will be considered a single building. Only true"no-thult"claims are counted toward the$10,000 limit. Claims for damages caused by city negligence,for which the city would be legally liable in any case,are not charged against that limit, What does it cost? The premium charge for ptional no-fault sewer back-up coverage will be 8.5%of the city's `-') municipal liability premiumbMCff Bard's intent is-that-this coverage option be supporting,so well be monitoring and if necessary adjusting these charges in the future. • 0"4 r r 2 , a � From:Kate Tipping At:Landmark Insurance Services FaxID:651-464-7596 To:Eric Johnson,City Admin. Date:3/82006 09:23 AM Page:5 of 6 OCT-17-2005 10:59 LEAGLE OF MN CITIES 6512811298 P.04 Is every city automatically eligible? No.The city will need to meet these underwriting criteria: • The city must have a policy and practice of inspecting and cleaning its sewer lines on a reasonable schedule. • If there are any existing problems in the city's system which have caused back-ups in the past or are likely to cause back-ups,the city must have and be implementing a plan to address those problems. • The city must have a system and the ability to respond promptly to back-ups or other sewer problems at any time of the day or week. • The city must have in place an appropriate program to minimize stormwater inflow and infiltration. • The city must have in place a system to maintain records of routine sewer cleaning and maintenance,and of any reported problems and responses. We'd stress that in making the underwriting evaluation we're trying to focus on reasonableness, rather than on creating very specific standards.That is,the intent isn't to set an arbitrary requirement that sewers be inspected and cleaned every six months or every three years or • whatever.What makes sense in one city with some older and sometimes sagging clay lines probably wouldn't make sense in a city with newer plastic lines,and vice versa.From the underwriting standpoint,the real concern is that the city has considered its own situation and developed polices,practices,and schedules that make sense for its own situation. How would the no-fault coverage work if we had a sewer back-up that was caused by city negligence.,and where the city was legally liable for the resulting damages? If the situation isn't one where the no-fault coverage applies,the city's LMCIT liability coverage • would respond just as it does now.That is,LMCIT would investigate and if necessary defend the claim cm the city's behalf,and would pay the resulting damages if in.fact the city is legally liable for those damages. The same would be true for damages that exceed the$10,000 no-fault limit,or for a subrogation claim against the city by the homeowner's insurance company.The city's existing LMCIT liability would respond just as it does now. What's the legal basis for this coverage?Wouldn't it he a gift of public funds to pay damages that the city isn't legally liable for? First,as noted earlier,one goal is to help reduce health hazards by encouraging prompt clean- ups.That's clearly a public purpose and in the public interest. From:Kate Tipping At:Landmark Insurance Services FaxID:651-464-7596 To:Eric Johnson,City Admin. Date:3/8/2006 09:23 AM Page:6 of 6 OCT-17-2025 11:00 LEAGUE OF MN CITIES G512E111298 P.05 • Second,the law and facts surrounding most sewer back-up claims are rarely so clear that the liability issue is entirely black and white.There's virtually always a way that a claimant's attorney can make some type of argument for city liability.Having this coverage in place should help eliminate the need to spend public funds on litigation costs in many of these cases. Finally,part of the process for putting the coverage in place is for the city council to pass a formal resolution that makes this no-fault sewer back-up protection part of the agreement between the city and the sewer customer.The idea is that by paying his sewer bill,the sewer user is purchasing not just sewer service but also the right to be reimbursed for certain specified sewer back-up costs and damages.In other words, the basis for the no-fault payments to the property owner would he the contract between the city and the sewer user. How do we put coverage in place? Contact your[MOT underwriter for an application.If the city qualifies for coverage, we'll send the city a formal quote, along with a model resolution. To put coverage in place,the city council must formally pass that resolution,and send a copy to LMCIT- If the city decides to add this coverage, it will also be important to make sure the citizens know about it.LMCIT can also provide models for a press release,newsletter article,utility bill insert, etc. • Who can we contact with questions or comments? Contact your LMCIT underwriter,or Pete Tritz at the League office. We're also interested in hearing cities' reactions to this new coverage option,especially if there are changes you'd like to see. PST MO/2003 S 4 TOTRL P.05 • • .41,71,14*, • • City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: Brian Alm Fax: 651-464-7596 From: Judy Holst Date: 8-11-05 Re: No Fault Sewer Back-Up Coverage Pages: 5 CC: ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Notes: Brian, Here is the No Fault Sewer Back-up Coverage Application we spoke about this morning. The City Council approved the Municipal Sewer Collection System Maintenance Standard plan at the Tuesday,August 16,2005 meeting. Will this take care of the information I need for the quote for coverage from LMCIT? Will I need a formal Resolution? Thanks, Judy S • , • • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST I 5. Documentation I Does the applicant maintain written records of its normal maintenance and inspections of the sewer system? , Yes ❑ No Does the applicant maintain written records for its cleaning and inspection of problem sewer lines? ( Yes❑ No gig /2-7.e 6. Planning Does the applicant havecpital improvements planning in place to remedy any ongoing problems with its sewer system? Yes❑ No Please provide etails including a description of t�@@ plan, availability of financial resources and timetables. p�j�diL. ./ Q-7/®� ! �P 4. 'b `/,iEA.E'L P 04 LS a £d s".,C.;e-7 /DR t)A)b //✓6 Wogie 44/.J0 R` LA)0/ (C I Special Note: No fault Sewer Back-up Coverage cannot be bound until the applicant has met the underwriting criteria and has passed a No Fault Sewer Back-up Resolution. • By: (Signature and Title of Authorized Representative) I I 4 I Pa e2of2 LMCITAPP.SEWERBU(11/00)(Rev. 11/03) g I ' LEAGUE OF MINNESOTA CITIES INSURANCE TRUST I NO FAULT SEWER BACK-UP COVERAGE APPLICATION I APPLICANT: e/7'11 "c dIi P/3/2 K / iz /5 AGENTS NAME: /<44.-T-t. /4,114(2 - L4 it lA1a r/ TELEPHONE NUMBER 651-y&y.-3 3 3 UI. Inspection and maintenance program Does the applicant have a ' tion and maintenance program? [ Yes 0 No Please describe briefly r attach a opy of the program. 1 I 2. Problem area identification procedures I Does the applicant have in place procedures for identifying and abating problem areas in the system that may require more frequent inspection or cleaning? (K Yes 0 No Please describe briefly. Iy, A- '-4- y RI CO9t S — ?LA,VN‘.6 //sip& I0 3. Emergency response system Does the applicant have a procedure for providing 24-hour/7 day emergency response to sewer Iback-ups? ( f.Yes 0 No Please describe briefly. 2 Co 5�l7 ¢', ',N -C -L T� 5 v(C-' r✓? c-� U.)/ V�.i./pi:)RS I 4. Inflow and Infiltration Procedures(Storm water getting into the sanitary sewer system) Does the applicant have an active plan to minimize the effect of storm water getting into the sanitary sewer system? [\Yes 0 No Please describe briefly. II l74 27 0 f--- az- U/ S/itiA f i--AiV /fwU A 3 ) / 5c- oa R- _.l.,) I I I I . I 11 LMCITAPP.SEWERBU(11/00)(Rev. 11/03) Page 1 of 2 • ° � Park H tr„ I.. Tree City USA 444.„,* ' eft THE CITY OF OAK PARK HEIGHTS MUNICIPAL SEWER COLLECTION SYSTEM MAINTENANCE STANDARDS Adopted by City Council Action on August 9, 2005 The City of Oak Park Heights owns 123,018 feet of gravity sewer lines of assorted type and sizes, 5 lift stations and 8,157 feet of related pressurized force mains as its wastewater collection system. Wastewater Treatment is performed by the Metropolitan Council Environmental Services (MCES). The City of Oak Park Heights is responsible for development of and adherence to standards to be used to maintain the city wastewater collection system. City staff is directed to provide for the maintenance of the collection system under the following guidelines: • • Staff shall arrange for cleaning the collection system using high pressure jetting. Approximately 32,000 feet (one-quarter of total sewer collection line footage) shall be maintained each year. Staff shall identify problem areas that have poor slopes, excessive roots, grease problems or problem pipes that require additional maintenance. These areas shall be cleaned more frequently, depending on the severity of the problems, up to and including yearly. Staff shall request appropriate ordinance changes, if needed, to protect the city infrastructure. Estimated costs for jetting operations are $25,000 per year. The entire system shall be completely cleaned at a minimum of every five years. • Staff shall arrange for televising the collection system for defects including failures, joint separations, excess roots, service intrusions, and have the problems documented and rated for maintenance and repair options. Televising shall be conducted to verify the acceptability and efficiency of cleaning and root removal operations. A record shall be made of all lines analyzed and recordings shall be kept to allow verification of conditions. Indications of excess inflow and infiltration shall be documented, as well as indications of improper discharges to the City of Oak Park Heights sewer collection system. Approximately 32,000 feet shall be televised the first year at an estimated cost of$19,000 and an additional 23,000 feet televised in each the following four years at an estimated cost of$14,000 in each of those four years. This will allow the entire system to be televised in 5 years. • The budget will remain constant for the 5 year period and the $5,000 decrease in costs g Y P • of televising in years 2 through 5 shall be dedicated for repairs identified in the previous year televising report. At the end of the five year period, the system evaluation shall be used to determine adequacy of the cleaning program, adequacy of the repair program, and the future needs. It is believed the televising shall not be a major ongoing expense after the system is completely documented and will only be used for specific problems or areas that indicate changes. It is anticipated the cleaning program will be and ongoing maintenance cost for the life of the system. • • Preventative maintenance at the City of Oak Park Heights five lift stations shall continue to be conducted on a bi-weekly basis. The staff shall continue to provide daily checks at each site. Weekly pump records shall be maintained to help identify excess pump hours or bypass or check valve problems. The pump control system shall be evaluated on a monthly basis for verification of pumps start, stop and alarm set points. Corrective maintenance on the system is a high priority and shall be made as discovered. The wet wells shall be evaluated on alternating months and clean outs and repairs implemented on a minimum of yearly basis and more often as indicated by the condition of the structure. The policy shall be to have two pumps available at each lift station during normal operations and to have repairs implemented within 48 hours if one pump becomes inoperable. Failure of a lift station shall be considered an emergency and pump or transport equipment shall be brought in to allow the continued use of the facility for sewer conveyance. • The City of Oak Park Heights shall evaluate the cost and availability of back up power at each of the lift stations. The current generator plug in at the Kern Center station shall be used as the standard for the remaining stations. It is the intent of the City of Oak Park Heights to have a plug in generator receptacle available at each lift station. We intend to add one new generator receptacle to a lift station each year. If budget allows, the purchase of a potable back up generator capable of operating all stations shall be investigated and a comparison of ownership costs/ availability of rental units shall be made. • • The City of Oak Park Heights' existing alarm system shall be evaluated for future upgrades. Backup power during power failures should be installed to run the exterior warning lights. Cost evaluations shall be made regarding the benefit of a Supervisory Control and Data Acquisition system (SCADA) central alarm and control system that would provide dedicated notification of potential problems as well as alarm conditions during any failure condition. Information on dedicated communication (radio or telephone) shall be investigated. A report on options shall be submitted to the Council for consideration. • The staff shall evaluate existing data and new televising records to address excess inflow and infiltration (1&I) discovered in the system in order to save excess treatment costs from clean water entering the system for treatment. The City of Oak Park Heights shall implement a plan to address I&I, if required by MCES. • • Oak Park Heights ENCLOSURE 4 Request for Council Action Meeting Date August 9, 2005 Agenda Item Title Adopt Sewer Maintenance Standard Time Required 0 min Agenda Placement Consent Originating Department/Requestor Public Works Director/Tom Ozzello 4111■ Requester's Signature i`,.« ` - Action Requested Adopt Standard Background/Justification The City of Oak Park Heights has a municipal sewer collection system serving the community. The system consists of 123,018 feet of gravity sewer lines of assorted type and sizes and 5 lift stations and 8,157 feet of related pressurized force mains. Actual Wastewater Treatment is performed by the Metropolitan Council Environmental Services (MCES). Over the years, city growth, ageing infrastructure, tree maturation and changes in . sewer use patterns (i.e. grease from restaurants, garbage disposals, low flush toilets, etc.) have raised concerns about the ability of the city to adequately maintain the collection system used to transport wastewater to MCES facilities for treatment. The League of Minnesota Cities Insurance Trust (LMCIT) insures the City of Oak Park Heights for liability costs caused by sewer back-ups. The city is required to have and follow a sewer maintenance plan in order to minimize the potential for sewer problems and adequately maintain the collection system. There is currently no formal maintenance plan for the collection system. We have a formal request from the LMCIT to document our plan and our procedures in order to continue coverage under the LMCIT Plan. In reviewing guidelines from LMCIT and professional municipal organizations as well as other cities in the metropolitan area served by MCES, the standards for collection system maintenance include: • cleaning the entire collection system over each 3 to 5 year period • televising the entire collection system and then update the televising over a recurring multi-year period • providing preventative maintenance at lift stations based on history and potential impact from failure • provide corrective maintenance at lift stations in a timely and consistent manner to avoid further damage • Provide corrective maintenance for sewer lines as needed and have a response plan for blockages • Though not currently required (may be mandated by MCES soon), a plan to address iexcess inflow and infiltration is strongly recommended to avoid overflows of sewer lines and excess treatment costs from rain water entering the sanitary sewer system and going to MCES for treatment (and billing to the city). Based on the above standards and a review of the City of Oak Park Heights collection system, Public Works has developed a Sewer Maintenance Standard (attached)we believe addresses the requirements of the LMCIT and provides a good minimum standard to address the current and future needs of the city and provides a reasonable level of protection and control from damage. Discussion The Water Environment Federation suggests 1/3 of the collection system be cleaned each year. The LMCIT suggested a minimum four year period. There are also areas (restaurants, car washes, poor slopes, Etc.)that may require yearly maintenance. Our past procedure has been to contract some cleaning with local service providers and call for emergencies as they develop. We are suggesting at this point that we provide a comprehensive plan to contact high speed jetters (internal pipe pressure washers) and root saws on 25% of the total city footage on a yearly basis. This will include re-cleaning some known problem areas each year. Because of the yearly repeat work we will not complete the City of Oak Park Heights collection system until the 5th year. Due to the unknown status of the current system and potential to need sewer evaluation done prior to street work, we are also suggesting we contract the televising and evaluation of the sewer lines after cleaning. The projected cost of this operation is estimated at $0.80 per foot for cleaning and $0.60 per foot for televising. There is extra cost anticipated for large root removal ($1.35 a foot)or pipe or service misalignment ($185.00/hour) and the yearly (un-televised after the first year) problem area jetting. The total estimated costs are based on a five year plan to complete the cleaning and televising of the system. The City of Oak Park Heights has allocated $30,000 in the 2005 budget for contracted maintenance. Approximately $25,000 of this will be used for cleaning the lines and $5,000 held for repairs. This amount currently meets the need for regular sewer line maintenance. A request has been drafted for an additional $20,000 to be added to this line item in the budget to initially cover televising the first year (estimated at$19,000) of a 5 year program and then $14,000 is subsequent years. The additional contract service dollars will be needed to make repairs and corrections to the collection system as defects (broken or separated joints, etc.) are discovered and for extraordinary services such as blockages and roots that require additional work. Cleaning and televising must be prioritized to cover any roads that are scheduled for repairs prior to the road work. Staff currently provides a daily inspection at lift stations and a preventative maintenance check twice a week at each lift station. This should continue. There is a warning light at each station for some failures and a dialer at one station for failures. The wet wells are inspected quarterly and the control system maintained on a monthly basis. Mechanical cleanout of debris is scheduled based on build-up and can range from 6 months to well over a year. We are recommending the inspections bi-monthly and, the debris removal be scheduled at least yearly on all stations and at 6 months at problem stations. Though not currently impacting operations we would suggest the following two improvements be made to the lift stations. (1) Install generator service connections at each lift station for use of portable back up generators. (2) Upgrade the control system to include battery back-up of alarms and a wireless communications of failures to a phone dialer for immediate staff notification of loss of power, pump failure, high levels or break in. The current system can not show an alarm light if the power is out and there are no dialers except at the 9th addition station. It is suggested the wells and water towers also tie in to the dialer system to notify staff of potential problems. Capital improvement plans (CIP) have been drafted to present these costs. • THE CITY OF OAK PARK HEIGHTS MUNICIPAL SEWER COLLECTION SYSTEM MAINTENANCE STANDARDS Request for Adoption by City Council Action on August 9, 2005 • The City of Oak Park Heights owns 123,018 feet of gravity sewer lines of assorted type and sizes, 5 lift stations and 8,157 feet of related pressurized force mains as its wastewater collection system. Wastewater Treatment is performed by the Metropolitan Council Environmental Services (MCES). The City of Oak Park Heights is responsible for development of and adherence to standards to be used to maintain the city wastewater collection system. City staff is directed to provide for the maintenance of the collection system under the following guidelines: • Staff shall arrange for cleaning the collection system using high pressure jetting. Approximately 32,000 feet (one-quarter of total sewer collection line footage) shall be maintained each year. Staff shall identify problem areas that have poor slopes, excessive roots, grease problems or problem pipes that require additional maintenance. These areas shall be cleaned more frequently, depending on the severity of the problems, up to and including yearly. Staff shall request appropriate ordinance changes, if needed, to protect the city infrastructure. Estimated costs for jetting operations are $25,000 per year. The entire system shall be completely cleaned at a minimum of every five years. • Staff shall arrange for televising the collection system for defects including failures, • joint separations, excess roots, service intrusions, and have the problems documented and rated for maintenance and repair options. Televising shall be conducted to verify the acceptability and efficiency of cleaning and root removal operations. A record shall be made of all lines analyzed and recordings shall be kept to allow verification of conditions. Indications of excess inflow and infiltration shall be documented, as well as indications of improper discharges to the City of Oak Park Heights sewer collection system. Approximately 32,000 feet shall be televised the first year at an estimated cost of$19,000 and an additional 23,000 feet televised in each the following four years at an estimated cost of$14,000 in each of those four years. This will allow the entire system to be televised in 5 years. • The budget will remain constant for the 5 year period and the $5,000 decrease in costs of televising in years 2 through 5 shall be dedicated for repairs identified in the previous year televising report. At the end of the five year period, the system evaluation shall be used to determine adequacy of the cleaning program, adequacy of the repair program, and the future needs. It is believed the televising shall not be a major ongoing expense after the system is completely documented and will only be used for specific problems or areas that indicate changes. It is anticipated the cleaning program will be and ongoing maintenance cost for the life of the system. • Preventative maintenance at the City of Oak Park Heights five lift stations shall continue to be conducted on a bi-weekly basis. The staff shall continue to provide daily checks at each site. Weekly pump records shall be maintained to help identify excess pump hours or bypass or check valve problems. The pump control system shall be evaluated on a monthly basis for verification of pumps start, stop and alarm set points. Corrective maintenance on the system is a high priority and shall be made as discovered. The wet wells shall be evaluated on alternating months and clean outs and repairs implemented on a minimum of yearly basis and more often as indicated by the condition of the structure. The policy shall be to have two pumps available at each lift station during normal operations and to have repairs implemented within 48 hours if one pump becomes inoperable. Failure of a lift station shall be considered an emergency and pump or transport equipment shall be brought in to allow the • continued use of the facility for sewer conveyance. • The City of Oak Park Heights shall evaluate the cost and availability of back up power at each of the lift stations. The current generator plug in at the Kern Center station shall be used as the standard for the remaining stations. It is the intent of the City of Oak Park Heights to have a plug in generator receptacle available at each lift station. We intend to add one new generator receptacle to a lift station each year. If budget allows, the purchase of a potable back up generator capable of operating all stations shall be investigated and a comparison of ownership costs /availability of rental units shall be made. • The City of Oak Park Heights' existing alarm system shall be evaluated for future upgrades. Backup power during power failures should be installed to run the exterior warning lights. Cost evaluations shall be made regarding the benefit of a Supervisory Control and Data Acquisition system (SCADA) central alarm and control system that would provide dedicated notification of potential problems as well as alarm conditions during any failure condition. Information on dedicated communication (radio or telephone) shall be investigated. A report on options shall be submitted to the Council for consideration. • The staff shall evaluate existing data and new televising records to address excess inflow and infiltration (l&I) discovered in the system in order to save excess treatment • costs from clean water entering the system for treatment. The City of Oak Park Heights shall implement a plan to address l&I, if required by MCES. No-Fault Sewer Backup coverage Page 1 of 2 c;,,,r ' League of Minnesota � `"i Cities Insurance Trust ,f,,,,--,.,-,,,, f....,..w.,.....,.a- r REMAKES 1 LEGISLATIVE i Lf4CIT f HA I LIBRARY I 0:INFERENCES I PUBLICATIONS I OTHER SE.' Search Tools No-Fault Sewer Backup Coverage ,.' =4` ,',°4 The new No-Fault Sewer Backup coverage is an extra-cost :. €I F .; option to LMCIT Property/Casualty members that may help cities i:,;_-,.^z protect homeowners from the damages of a backup that occurs at no fault of the city or homeowner. The coverage includes the cost of replacing and repairing damaged property resulting from a sewer backup, as well as clean-up and disinfection cost. -_ i'7,„ To qualify for this coverage, cities need to have an appropriate '. a : program for regular inspection and maintenance of their sewers. [;;:' City's claim history will also be reviewed to determine eligibility. -`'' ° '' ii&I. f 11' LMCIT recommends that cities obtaining No-Fault sewer backup • :r:_, a;Z'ii coverage pass a resolution(sample resolution) and communicate with residents regarding what they can expect from this new :;=:. •1 '✓'` is c coverage (tips on how to communicate this development to ,,,,„ .A,�- 7 your citizens.) ,.m,€ y. L, Li If you have any questions about this new coverage,please contact { Pete Tritz or your LMCIT underwritter. Claims Reporting Employee Benefits (1151- Property Casualty I Workers' Compensation JJ ,,, Loss Control I LMCIT Library Conference Registration Ayr ,. v. i '~ City Resources 1 Legislative I LMCIT HR 1 Library .V /V ()?', ' N ' w Conferences I Publications I Other Services y �N Ii Home I Site Features &Tips I Web Site Policy I Site Search CC LMC Staff I What We Do I Press Room 1 ` ` Sponsorship &Advertising Opportunities I Cities Vendor Guide I Links ' t v Copyright©2005 League of Minnesota Cities I:" /J -, 145 University Ave. West,St.Paul,MN 55103 'k U ' • r �: Phone:651-281-12001 Toll Free: 1-800-925-1122 i' Fax:651-281-1299 i TDD:651-281-1290 • Comments about the Site?Contact the Webmaster ° i),. 9 ., I http://www.lmnc.org/Imcit/sewer.cfm 8/17/2005 • Resolution# RESOLUTION ESTABLISHING LIMITED SEWER BACK-UP CLEAN UP AND PROPERTY DAMAGE PROTECTION FOR MUNICIPAL SEWER CUSTOMERS. RECITALS WHEREAS,the city affords municipal sanitary sewer services to many of the property owners within the city; and WHEREAS, on occasion blockages or other conditions in city sanitary sewer lines may result in the back-up of sewage into properties that are connected to those city sanitary lines; and WHEREAS, sewer back-ups into property pose a public health and safety concern; and WHEREAS, it is not always easy to discern the exact cause and responsibility for municipal sanitary sewer back-ups, and WHEREAS,the City Council desires to encourage the expeditious clean-up of properties that have encountered sewer back-ups; and • WHEREAS, the City Council desires to minimize the potential of expensive lawsuits arising out of sewer back-up claims, and WHEREAS, the City is a member of the League of Minnesota Cities Insurance Trust; and WHEREAS,the League of Minnesota Cities Insurance Trust is making available to the city a limited"no fault" sewer coverage that will reimburse property owners for certain clean-up costs and property damage irrespective of whether the City is thought to be legally at fault. NOW THEREFORE, BE IT RESOLVED, by the City Council of , Minnesota, as follows: As part of the contract for the provision of sewer services to the customers of the City, and in consideration of the payment of sewer bills, the City agrees to reimburse its sanitary sewer customers for up to $10,000 of clean-up costs and property damages caused by a sanitary sewer back-up, irrespective of whether the city is thought to be negligent or otherwise legally liable for those damages, subject to the following conditions: a. The back-up must have resulted from a condition in the city's sanitary sewer system or lines, and not from a condition in a III private line. • b. The back-up must not have been caused by catastrophic weather or other event for which Federal Emergency Management Assistance is available c. The back-up must not have been caused by an interruption in P electric power to the city's sewer system or to any city lift station, which continues for more than 72 hours. d. The back-up must not have been caused by rainfall or precipitation that would constitute a 100-year storm as determined by the National Weather Service. e. Neither the city nor the League Minnesota Cities Insurance Trust (LMCIT) will reimburse any costs which have been or are eligible to be covered under the property owner's own homeowners or other property insurance, or which would be eligible to be reimbursed under a National Flood Insurance Protection(NFIP) policy,whether or not the property owner actually has NFIP coverage. f. The maximum amount that the City or LMCIT will reimburse is $10,000 per building per year. In this regard, a structure or group • of structures served by a single connection to the city's sewer system is considered a single building. Adopted by the council this day of(month),(year). City Clerk Mayor • a•2, • City of Oak Park Heights 14168 Oak Park Blvd. N•Box 2007•Oak Park Heights,MN 55082•Phone(651)439-4439•Fax(651)439-0574 4 August),2005 Mr.Mark Casey Senior Loss Control Consultant Berkley Risk Administrators,LLC 222 South Ninth Street,Suite 1300 Minneapolis,MN 55402-3332 RE:Loss Control Recommendations Dear Mr.Casey, It is my understanding that your firm may be holding up the process towards the City receiving its new costs for the upcoming year due to our possible non-response to your July 28th and October 4th (2004) letters on two loss control items. As you recall,you and I discussed these issues last year and I had indicated to you that: 1) The City has not had a written policy on sewer backups to date and that we are working on one now.This however did/does not mean that the City does not,in a verifiable way,maintain its sewer systems.I had also indicated to you at that time that the City had hired a new Public Works director and that it would take some time for him to acclimate and prepare this plan; 2) The City does have a written policy on sexual harassment that applies to all employees, including temporary hires. Enclosed you will find a draft copy of our sewer maintenance plan/policy that has finally been completed by the Director of Public Works.The policy is slated for City Council adoption on August 9th,2005.Also enclosed is a copy of our City Ordinance 203—Personnel Policies that have been given to the temporary employees,obviously the City cannot afford to send temporary,non-management staff to various personnel training so we endeavor to make them keenly aware that the policies apply to them in total. If you feel you need more inform. 'on and are thus delaying the fmal underwriting of our upcoming policies,for these minor issue .1:.se let me know as soon as possible.If your firm has any video tapes that quickly addres •t: issu, tha . e discussed herein please forward it to me. Sincer. , Jo t ,sot City • •tt't stator Cc: Judy Holst, o e losures Kate Tippin:, enclosures • Page 1 of 1 Judy Hoist From: Judy Hoist Sent: Thursday, August 04, 2005 3:13 PM To: Kate Tipping (balm @landmark-ins.com) Subject: 7-7-05 renewal Hi Kate, I have the answers you requested on your 7-29-05 fix regarding the generator and the Bell property. The generator was manufactured at Woodward Governor Company, Ft. Collins, Colorado. It was manufactured Oct. 1995 Serial# 11463832—Caterpillar 3306B TA Diesel—205 KW Prime Power/225 KW Standby-XQ225 Portable Generator Unit 471 The Bell property is vacant land. Eric had spoken with the rep from LMCIT at the time he was out here. Eric informed Mr. Casey at the time that the City has a written policy on sexual harassment that applies to all employees, including temps and that we were working on the Sewer Plan. The Sewer Plan is going for approval at next week's Council meeting and Eric will be sending a letter to Mr. Casey after the Sewer Plan has been approved. Let me know if you need anything else. Judy • 8/4/2005 Page 1 of 1 Jeff Kellogg • From: Judy Hoist Sent: Thursday,August 04, 2005 10:59 AM To: Jeff Kellogg Subject: FW: Equipment Breakdown Insurance Coverage From: Judy Hoist Sent: Monday, August 01, 2005 9:12 AM To: Tom Ozzello Cc: Eric A.Johnson Subject: Equipment Breakdown Insurance Coverage Tom, I have asked for a quote from out insurance company for Equipment Breakdown. This would cover furnaces, air conditioners, generator, etc. (like boiler& machinery coverage). They are requesting some information on the generator. Could you please give me info on the following: 1, age/year manufactured 2. KVA? 3. Make and model of the generator • Please let me as soon as you are able. Thanks, Judy � ) n /II trak at `''� U6 1 z- / -r2t( co-eeezn4 , c.„0,--eez-eteter-, fir 15' .,Qiuve - l 1 146 3 t 33066 TA 00 --e-;24--e-C 4-to_2-( it4) s27"-e931 a7 05 kut) ,(4,olto ro (2_ • LI 7( 8/4/2005 From:Kate Tiooina At:Landmark Insurance Services FaxiD:651-464-7596 To:JUDY Date:7!2912005 01:48 PM Pace: 1 of 2 Phone: (651) 464-3333 ext. 209 Fax: (651) 464-7596 • Fax From: Kate Tipping To: JUDY Pages: 2 Fax: (651) 439-0574 Date: 7/29/2005 01:47:57 PM Phone: (651) 439-4439 Subject: Underwriting questions Message: • From:Kate Tipping At:Landmark Insurance Services FaxID:651-464-7596 To:JUDY Date:7/29/2005 01:48 PM Page:2 of 2 t •KateTiPPing From: Brian Alm Sent: Friday, July 29, 2005 1:30 PM To: Kate Tipping Subject: FW: City of Oak Park Heights Original Message From: Mingee, Pat [mailto:PMingee @LMNC.ORG] Sent: Friday, July 29, 2005 9:57 AM To: balm @landmark-ins.com Subject: City of Oak Park Heights Re: 7-7-05 renewal Hi Kate A couple of things that I need your help with: 1. equipment breakdown coverage-per last year, we will need to send info about the diesel generator to our Hartford Steam Underwriter for approval prior to providing the city with a quote. Please advise - A. age/year mfg B. KVA? C. Make and modle of the generator •2. is the Bell property still vacant? Just land or are there buildings? Thanks Patricia M Mingee CPCU, CIC LMCIT Underwriting phone: (651)215-4081 or (800) 925-1122 ext 4081 fax: ( 651)281-1298 email: pmingee @lmnc.org This email has been scanned by the MessageLabs Email Security System. For more information please visit http://www.messagelabs.com/email • 1 City of Oak Park Heights Page 1 of 2 Judy Hoist From: Eric A. Johnson Sent: Monday, August 01, 2005 1:58 PM To: Judy Hoist Subject: Berkley Underwriting 2005-2006 costs Attachments: image001.png Judy, This letter is going out when Tom 0 gets me the sewer mgmt plan eric II City of Oak Park Heights 14168 Oak Park Blvd. N•Box 2007•Oak Park Heights,MN 55082•Phone(651)439-4439•Fax(651)439-0574 August 1,2005 Mr.Mark Casey Senior Loss Control Consultant Berkley Risk Administrators,LLC 222 South Ninth Street,Suite 1300 Minneapolis,MN 55402-3332 RE: Loss Control Recommendations Dear Mr. Casey, It is my understanding that your firm may be holding up the process towards the City receiving its new costs for the upcoming year due to our possible non-response to your July 28th and October 4th (2004)letters on two loss control items. As you recall,you and I discussed these issues last year and I had indicated to you that: 1) The City has not had a written policy on sewer backups to date and that we are working on one now.This however did/does not mean that the City does not, in a verifiable way,maintain its sewer systems.I had also indicated to you at that time that the City had hired a new Public Works director and that it would take some time for him to acclimate and prepare this plan; 2) The City does have a written policy on sexual harassment that applies to all employees,including temporary hires. Enclosed you will find a draft copy of our sewer maintenance plan/policy that has finally been completed by the Director of Public Works.The policy is slated for City Council adoption on August 9th,2005.Also enclosed is a copy of our City Ordinance 203—Personnel Policies that have been given to the temporary employees, obviously the City cannot afford to send temporary,non-management staff to various personnel training so we endeavor to make them keenly aware that the policies apply to them in total. 8/1/2005 City of Oak Park Heights Page 2 of 2 If you feel you need more information and are thus delaying the final underwriting of our upcoming policies,for these minor issues,please let me know as soon as possible.If your firm has any video tapes that quickly address the issues that are discussed herein please forward it to me. Sincerely, Eric Johnson City Administrator Cc: Judy Hoist,no enclosures Kate Tipping,no enclosures • • 8/1/2005 From:Kate Tiooina At:Landmark Insurance Services FaxiD:651-464-7596 To:Eric Johnson,City Admin, Date:728/2005 03:51 PM Pace:1 of 2 Phone: (651) 464-3333 ext. 209 Fax: (651) 464-7596 • ":7'1� it,xts From: Kate Tipping To: Eric Johnson, City Admin. Pages: 2 Fax: (651) 439-0574 Date: 7/28/2005 03:51:21 PM Phone: (651) 439-4439 Subject: Loss Control, etc. Message: • • From:Kate Tipping At:Landmark Insurance Services FaxID:651-464-7596 To:Eric Johnson,City Admin. Date:7/28/2005 03:51 PM Page:2 of 2 MEMO Page1 Landmark Insurance Services r x � ; rV. .� i . ,�"/, � , �f :. ": 232 South Lake Street , ,;14 ' 0 ', • Forest Lake,MN 55025 OAIAA 1 hT 07/28/2005 Phone: 651-464-3333 Fax: 651-464-7596 0111 mi'' ' ' ' CMC25101 PANAIWONMANZRAIMMANNAMMINWANKARMENIENE CP 07/07/2004 07/072005 City of Oak Park Heights 14168 Oak Park Blvd PO Bx 2007 Oak Park Heights,MN 55082-6476 .,i. � v d "N y 'a . ea ��� / 'jam"w J 1 . , ' its } ° ide rrr ih a � �. "N I left a voice mail for your underwriter at the LMCIT on 7-25, she didn't call me back, but I recieved this by fax today. The lack of response may be holding things up. Any recommendations like these merely need a written response, not necessarily immediate action. Their original request was mailed a year ago, so I can understand their concern. If someone responded last year, please send me a copy of that response. If you have questions prior to resonding, please give me a call . Thank you. SPS - hopefully then I can get you the numbers you need for the budgets - though - other than value increases - I 've seen very little increase in rates. 4-5% is usual for value increases as well as expenditures that drive the Liability premiums . Kate Tipping • 07/28/2005 THU 14:50 FAX Z 001/004 JUL-29-2005 12:50 LEAGUE OF MN CITIES 6512811298 P.01 • • FAX TwANSMISSION LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • 145 University Avenue West St.Paul,Minnesota 55103 Telephone(651)281-1200 LQagua i Minnesota Cities Facsimile(651)281-1298 Cities pron+ofieg axrallanae To: Kate Tipping From: Pat Mingee CPCU CIC LMCIT Underwriting Fax Number: 651-464-7596 Total Pages: 4 including Cover Date: Jams r �� y$- o - • Subject: City of Oak Park Heights Re:Loss Control Recommendations A letter listing a number of Loss Control recommendations was sent to the Administrator of the City of Oak Park Heights on October 4,2004 with a copy to your office. To date,we have not had any response to the status of those recommendations. Please contact the City and advise when a response to the recommendations will be done? Let me know if we can assist in any way. Thank you for your attention to this matter. 1 am enclosing another copy of the recommendations for your review. Please deliver this facsimile transmission to the above address. If you did not receive all of the pages in good condition,please advise Pat Mingee at(651)215-4081/800-925-1122 ext.4081. `f3q- 05)`t 07/28/2005 THU 14:50 FAX 1j002/004 JUL-28-2005 12:50 LEAGUE OF MN CITIES 6512811298 P.02 • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST Loss Control Services Administration: cJn Berkley Risk Administrators Company,LLC 222 South Ninth Street,Suite 1300,Minneapolis,Minnesota 35402.3332 League of Mlwnasnto C�6oc Phone:(612)766-3000 Fax:(612)766.3199 Web Site: www.lmnc.org Ciliar prvrnal+rg auclkncc NO RESPONSE October 4,2004 /2/O/0)7 c'>/ Date: Mr.Eric Johnson LCC: ` - Administrator 1' City of Oak Park Heights 14168 Oak Pak Blvd. Oak Park Heights, MN 55082 Dear Mr.Johnson: • A later listing a number of loss control recommendations was sent to your attention on July 26,2004 A copy of that letter is attached for your reference. These loss control recommendations were a result of a recent loss control survey of the premises and operations of the city in conjunction with the city' participation in the League of Minnesota Cities Insurance Trust property and casualty program. According to our records, we have not as yet received a response to this recommendation letter. Would you please advise me of the steps you have taken to address these toss control recommendations?Feel free to write your comments direct s a thrflo,mTeridation letter and return II to me. Return With File Thank you for your assistance. Put in File , Sincerely, �•~�""° Xg/ Mark E. Casey, CSP, ARM, ALCM Senior Loss Control Consultant Berkley Risk Administrators Company,LLC Enclosure c: Forest Lake Insurance Agency, 232 South Lake Street,Forest Lake, MN 55025-2605 • ote_ria.° 1 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER �_. ,» ,. M .�••_._...... M_. 07/28/2005 THU 14:51 FAX 21003/004 JUL-28-2005 12:50 LEAGUE OF MN CITIES 5512811298 P.03•• L me LEAGUE OF MINNESOTA CITIES INSURANCE TRUST Loss Control Services Administration- do Ecrklcy Risk Adrr niatra�ters Cornpeny,LLC l.eagua of Minnorota Crew 222 South 9th Srreet,Suite 1300,Minneapolis,Mitutesow 55402.3332 Phone; (612)766-3172 Fs i (612)766-3199 (iliac pro eol,,ig aweeflonto Web Sire: www.lntnc.org July 28,2004 Mr. Eric Johnson City Administrator City of Oak Park Heights 14168 Oak Park Blvd Oak Park Heights, MN 55082 Dear Mr;Johnson: A routine loss control survey was recently conducted concerning certain premises and operations for the city.This was_in conjunction with the City's participation in the League of Minnesota Cities Insurance Trust (LMCIT) property, liability and workers' compensation program. The purpose of my visit was to assist the city in the reduction of potential loss through loss control and risk management activities. As a result of this loss control survey, I have developed the following recommendations. We have found that compliance with loss control recommendations can assist in minimizing the potential for loss. 1/7/04 Sewer cleaning should be scheduled on a continuing basis to ensure that priorities are maintained S for sewer mains that have blocJca9e problems such as tree roots, grease buildup or design problems that Impede proper flow. Most cities develop a schedule that provides a complete cleaning of city sewer mains on a 3 to 5—year ' basis. Written records are kept on file on sewer cleaning, lift station checks and other maintenance.Video taping is also useful In establishing priorities and maintain records of cleaning and repairs. 2/7/04 Seasonal employees should provided formal training in appropriate employment policies such a sexual harassment prevention to ensure that they understand them and will comply with them. The long-term benefits and successes that can be enjoyed by a cooperative, self-insurance organization depend upon serious and careful consideration of loss control recommendations. In that context, we ask that you keep us Informed of the steps you take to address these toss control recommendations. Therefore, please respond within 60 days of your receipt of this letter regarding the status of how you Intend to respond to these loss control recommendations. I appreciate the time and courtesy extended to me at the time of my loss control visit, If I can be of any assistance before my next visit, please do not hesitate to contact me. Sincerely, �/�> a4J 61.E MadeCS ARM L M y ,A C Senior Loss Control Consultant Berkley Risk Administrators Company. LLC Enclosure:Sewer maintenance log • AN GQUAL OPPORTUNrrY/AFFtRMATtVE ACTION SMrt.OYER 07/28/2005 THU 14:51 FAX W1004/004 JUL-28-2005 12 51 LEAGUE OF MN CITIES 6512811298 P.04 • Page 2 CC: FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST PORES T .LAKE MN 550252605 Recommendations and comments are provided for loss control and risk exposure ituprovernont purposes only in conjunction with the insurance program referenced above. They are not made for the purpose of complying; with the requirements of any law, rule or regulation. We do not infer ar imply in the making of these reeo,nxnendatlons and comments that all aitee were reviewed or that all possible hazards were noted. The final responslhility for conducting loss control and risk management programs must rest with the insured. • s • TOTAL P.04 CITY OF OAK PARK HEIGHTS r A y 14168 Oak Park Boulevard No. • P.O.Box 2007 • Oak Park Heights,MN 55082-2007 • Phone:651/439-4439 • Fax:651/439-0574 July 6,2005 Kate Tipping Landmark Insurance Services 232 S. Lake St. Forest Lake, MN 55025 Dear Kate: Enclosed is the renewal application for the City's LMCIT Insurance Policy along with a copy of the December 31, 2004 Annual Financial Report. The City is currently working on the application for No Fault Sewer Back-up. The maintenance program and policy will be going to Council for approval next Tuesday. We should have the application completed within 30 days. • I would also like a quote on Equipment Breakdown and a quote on increasing the Excess Liability to $2,000,000. We will also require an Insurance Binder until we receive the 2005/2006 policy. Thank you, /74,4,74-- �H lst Y Deputy Clerk/Finance Director • • Tree City U.S.A. i • PROPERTY/CASUALTY COVERAGE APPLICATIONS • ' League of Minnesota Cities Cities promoting exce fence League of Minnesota Cities insurance Trust 145 University Avenue West St. Paul, MN 55103 Phone: (651) 281-1200 Fax: (651) 281-1298 Website: http://www.lmnc.org • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST LIABILITY COVERAGE -WAIVER FORM • Cities obtaining liability coverage from the League of Minnesota Cities Insurance Trust must decide whether or not to waive the statutory tort liability limits to the extent of the coverage purchased. The decision to waive or not to waive the statutory limits has the following effects: . If the city does not waive the statutory tort limits, an individual claimant would be able to recover no more than $300,000.on any claim to which the statutory tort limits apply. The total which all claimants would be able to recover for a single occurrence to which the statutory tort limits apply would be limited to$1,000,000. These statutory tort limits would apply regardless of whether or not the city purchases the optional excess liability coverage. • If the city waives the statutory tort limits and does not purchase excess liability coverage, a single claimant could potentially recover up to $1,000,000. on a single occurrence. The total which all claimants would be able to recover for a single occurrence to which the statutory tort limits apply would also be limited to $1,000,000., regardless of the number of claimants. . If the city waives the statutory tort limits and purchases excess liability coverage, a single claimant could potentially recover an amount up to the limit of the coverage purchased. The total which all claimants would be able to recover for a single occurrence to which the statutory tort limits apply would also be limited to the amount of coverage purchased, regardless of the number of claimants. Claims to which the statutory municipal tort limits do not apply are not affected by this decision. This decision must be made by the city council. Cities purchasing coverage must complete and return this form to LMCIT before the effective date of the coverage. For further information, contact LMCIT. You may also wish to discuss these issues with your city attorney. • ( .tji ft..' ti.,0 accepts liability coverage limits of$ t O00 1 000• from the League of Minnesota Cities In- ance Trust (LMCIT). The city DOES NOT WAIVE the monetary limits on municipal tort liability established by -Minnesota Statutes 466.04. .14 The city WAIVES the monetary limits on tort liability established by Minnesota Statutes 466.04, to the extent of the limits of the liability coverage obtained from LMCIT. ,E to of city council,meeting ..w - 8'-0 b' �� n Sig iature/Date \ P r �� -/ds Pgsitianl✓-sp L.s f/7' Z �-c ,9,L . Return this completed form to LMCIT, 145 University Ave. W., St. Paul, MN. 55103-2044 • LMCIT(11/00)(Rev.11/03) Page 1 of 1 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 145 University Avenue West St. Paul, MN 55103 (651) 281-1200 APPLICATION FOR: C ci O ce- C ? 1-(- U County: LOc yk,,,„ CA", Mailing Address: 14 ((o c e8Jj_ R.04-k '>L Phone: (prj t • t{3°t "0 `f 39 City, State, Zip: G AJc. ow tc- t 5 /1 .j 5 5 —Co(41(p Contact Person: I er;L C pav1 Title: C.i 44.1 ackvIA-6∎1■i g.)v• ar 2000 Census Population: 39 61 Current Estimated Population: Li 75 . Total Expenditures All Operations: 3R-7, '/)s- Is the applicant a Member of The League of Minnesota Cities? NYes nNo Submitting Agency: ( L01 (c.. (v t.4-ii CV.Ct Sem ult.-4i)— Address: R32. Laau3- 5)(-• S • City, State,Zip: c-ar..c " Cr.. • / w) n) S SC)15 Telephone: ((ost ) tfYCE- 3333 Facsimile: (Of ) (OP /5A Agency Contact: l t-ti �aw� Email Address: balm Q,A.(o•v maw(G -435.pcwt Date of Council Resolution or Contract Appointing the Agency: AGENT COMPENSATION: ® 10% n City Will Compensate the Agent Directly n Other Please specify: Standard Deductible: S00 (Applies to All Lines. Optional All Lines Deductibles are Available.) Current Information on Coverage You Are Applying For: Carrier Policy Type Expiration Date Premium I..MG 1 1 ?o„citc. 0 -7 0 L{ • Lg." H( lib LMCITAPP(11/97)(Rev. 11/03) Page 1 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PROPERTY/MOBILE PROPERTY COVERAGE The General Limit of Coverage per Occurrence is the sum of the estimated replacement costs of the building, contents, property in the open, builders risk property, and mobile property. BUILDINGS/CONTENTS/PROPERTY IN THE OPEN Attach updated schedule of buildings/contents, and property in the open. Please identify any vacant properties on the schedule. MOBILE PROPERTY -GREATER THAN $25,000 2003 14.4.474.-6-• Attach updated schedule of mobile property with replacement cost values greater than $25,000. • MOBILE PROPERTY -$25,000 OR LESS Mobile ro ert with replacement cost values of$25,000 or less can be covered with no schedule. P P Y re P There is a flat premium charge. Do you want this coverage?XES ONO CRIME COVERAGE The covenant automatically provides a$100,000 per occurrence limit for crime losses, with no additional premium charge. LMCIT provides coverage for theft, disappearance and destruction-inside, theft disappearance and destruction-outside, and forgery and alteration. The coverage is now a blanket limit with no location limitations. If you need additional limits, please contact your LMCIT Underwriter. • LMCITAPP(11/97)(Rev. 11/03) Page 2 of 21 0 .......i. 1 n rt • v NO Q I . 0 N N 01 � . O. -� n ,0) V V y 5 t t. L 4 V V s c v - 0 a - ..t t o 0. -. O O O 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 a N N 0 0 L) n 0 0 o .- N U o .Y I C I 0 L 4, Z Z Z Z 2 2 Z Z Z Z Z Z Z Z Z Z 2 2 Z Z 2 •$ o Q. >~ • H o N I W 0 0. N 1. ~,,, . 0 -00 re C O: Z C C C C E C C C C C OC C C C CI N O O• 0 S S LL M LL '� IL S S LL LL 9 It Y. LL 2 2 2 2 S 2 S A W .. 0 W O F %O M o in N co O If1 40 V V O .O 0 M 0 0 0 4• • 0 n co a0 ,j• as b N 43 '0 M N f� I. 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N VO N 0O I 2 3 0 3 0 0 o O O 0 o o O .i .-1 .4 .•1 N .4 N .4 .4 ' ..1 C J Z 0 0 0 0 0 0 0 O 0 0 0 0 0 0 0 0 0 0 1 • • M N 0 CO 45 a 4+ c u '4 ns HI U r, V � O CO N 0 O N N 70 0 N o O O V I U O �e W C U �t •L Z Z Z .4• 0 In I xx • W CL 0 N W N C O 0 Z u E LS P 1 cn U O • N N O �p U W n c�� tg a h••I O m J H 0 u H u m eL P4 gd 1 H a 1 Fi , m a re L 1W- 7 Z t 1 C < J H Z J H W H Y M 0 N 0 .-1 ix 3 1 .oi u0. 00 cee hg ce N Z 00 41 d a a O. O. N N Z - N S N • O CC J u J 0 0 03 Q Z 0. X OC S • H• = 000 0 N V E Z E 0.0 U -L O N I L L a F-es 0 I- d • Y Q no 0 .1 J an Q 0 o \ o Z c N 0 0 0 a c m Z o 0 0 Z 0. O C 0 E 0 .•i . 0 0 ...I CC _i Z N 0 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST WATER AND SUPPLEMENTAL FLOOD COVERAGE APPLICATION 1. Does the applicant have locations in a flood hazard area? PP any If yes, has the maximum amount of NFIP flood insurance coverage been purchased? 2. Please provide the following information for any location where you are interested in the NFIP Supplemental Flood Coverage from LMCIT. Note:NFIP flood insurance coverage must be at the maxi mum amount of insurance available for the LMCIT Supplemental Flood Coverage to be available. Please contact your Underwriter for further information. • ■ ■ LMCITAPP(11/97)(Rev. 11/03) Page 3 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PROPERTY Unless specifically named, the following entities are not covered for property coverage. If property coverage is desired, please indicate below. If any of the entities have property coverage elsewhere, please provide details below. HOSPITALS OYES ❑NOON/A NURSING HOME OYES ONO 'IN/A HEALTH CLINICS OYES ONO :AN/A AIRPORTS OYES ONO Ki N/A ELECTRIC UTILITY OYES ONO ►N/A GAS UTILITY DYES ONO /5 N/A STEAM UTILITY OYES ONO N/A HRA OYES ❑NO" /9-c7,.,!/!7"% EDA ' YES ONO ❑N/A PORT AUTHORITY OYES ONO r4 N/A ADDITIONAL INFORMATION: G./ d`/G �4 ��- 670/n!'ox/. 't,2cr4pu'rc. l oil `+/r' C ��� Tr-I, A 1 !•cr X C t/ re? e..t._7" ' . '2O ;... a p rei lire.( o r i/'o7.O-O 'J T 7t • LMCITAPP(11/97)(Rev. 11/03) Page 4 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST INSTRUCTIONS FOR LMCIT EXPENDITURE WORKSHEET • Line I All expenditures—include all operating expenses, capital outlay, capital projects, debt, service (principal and interest)for the following: General Fund o7 79,3 a7 _ Debt Service / 7w Enterprise Fund !'' �� �b Port Authority Special Revenue Funds Nursing Homes Capital Improvement Funds (-S— Hospitals Airports Clinics HRA Other(please describe) EDA } Line II Transfers Out Line III Please list the expenditures for the categories shown on Lines III. a—i). These expenditures may be deducted if LMCIT is NOT providing E & 0 Coverage for these operations. Line IV Adjust total expenditures is the total expenditures for those departments and operations that have E&O Coverage with LMCIT. 5 Line V GL Deductions: A. Please list expenditures for the categories shown on Lines V. a—m). These deductions are necessary to subtract expenditures for operations or departments where the exposures are individually rated. B. Work performed by contractors which includes capital projects or services are also subtracted. For Your Information a) Contracted Services—All Operations: Expenditures should be deducted if the services are provided by others and they provide a Certificate of Insurance. b) Debt Services (principal and interest) c j) Please indicate expenditures for these operations (minus contracted services and debt services) m) Special Deductions: There may be some special deductions that are appropriate. Please list these special deductions or list them with your underwriter. that will be used to develop a portion of the liability VI The operating expenditures are the expenditures haw p p Y premium. Individually rated exposures are used to develop the remainder of the final premium. PLEASE ATTACH A COPY OF THE LATEST CPA AUDIT AND/OR THE PROJECTED BUDGET(WHICHEVER REFLECTS THE EXPENDITURES ON THE WORKSHEET.) THIS INFORMATION WILL ASSIST UNDERWRITING IN ANSWERING ANY QUESTIONS WITH REGARD TO THE EXPENDITURES WORKSHEET. LMCITAPP (11/97)(Rev. 11/03) Page 5 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST LMCIT EXPENDITURES WORKSHEET • �j Applicant: C ° °`�L i' � n ' Budget Year a00 7 All Expenditures ,5'8 it/78" II. Transfers Out Ill. E&0 Deductions a) HRA b) EDA c) Port Authority d) Nursing Homes e) Hospitals f) Airports g) Clinics h) Utilities(Water,Electric, Gas and Steam) i) Liquor Store Cost of Goods Sold(if included in I.) IV. Adjust Total Expenditures(E&0) 411 V. GL Deductions a) Contracted Services 1 3 5-4 b) Debt Service c) Water Department Only aS1-7 90/ d) Electric e) Steam f) Gas g) Liquor(Operating Expenses Only—Do Not Include cost of goods sold) h) Recreation Buildings(Arenas, Sr.Citizens Centers, Ice Arenas) i) Swimming Pools j) Golf Courses k) Individual Purchases which exceed 5%of the adjusted total expenditures (E&0) (List&Describe) I) Operations or departments that have E&O Coverage with LMCIT, but have their own General Liability with another insurance company. m) Special Deductions (List and Describe) VI. Operating Expenditures (GL) 3g? I ' LMCITAPP(11/97)(Rev. 11/03) Page 6 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST MUNICIPAL LIABILITY- SEPARATELY RATED EXPOSURES DO NOT LEAVE ANY SPACES BLANK IF NO EXPOSURE PLEASE INDICATE N/A OR NONE Applicant: CZ �+! Oc L t- tt.-1%-i-/l' Date G -30-0 S 1. Golf course annual receipts: vrt,ov- - Number of golf carts rented out: 2. Street mileage: (Round to nearest mile, i.e.4.2 miles should be 4) 3. Area (square feet)of Exhibition Buildings, Recreation Centers, Arenas, Auditorium or Community Centers: 4. Water Department payroll: /3 7, 4(a7 4111 Total gallons of water pumped annually: a�3v7 ' (Round to nearest million, i.e. 2,500,000 should be 3,000,000) 5. Electric Department payroll: ■ •12' 6. Gas Department payroll: 7. Steam Department payroll: 8. Number of powered boats: Horsepower and usage of each: • 9. Number of boats and canoes not powered: Explain how they are used: LMCITAPP(11/97)(Rev. 11/03) Page 7 of 21 • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 10. Municipal liquor store receipts: Store 1 Store 2 Store 3 On Sale Off Sale 11. Number of seasonal swimming pools: y\.O%N.A. Height of diving boards: 12. Number of inside swimming pools: Height of diving boards: 13. Number of swimming beaches: Height of diving boards: Number of docks and rafts: 14. Number of water slides: Heights: Length Location: Seasonal: Year Round: 15. Does the pool(s)comply with the.Minnesota Department of Health revised Chapter 4717, Public Swimming Pool Rules effective January 4, 1995, concerning water depth requirements for diving boards and pool decks? Yes❑ No❑ 16. Number of staff attorneys: V�CJhR- Do you want coverage to be excluded? Yes❑ No❑ Additional Information May be Necessary 17. Does the Applicant want to exclude medical payments? Yes❑ No LMCITAPP (11/97)(Rev. 11/03) Page 8 of21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST MUNICIPALITY QUESTIONNAIRE 411° DO NOT LEAVE ANY SPACES BLANK, IF NO EXPOSURE PLEASE INDICATE N/A OR NONE Applicant: c Oc . cc i kG T Jam " Date ' 3© O5 .followin e 1. Does the applicant own or operate any of the following? anti i r 3 1 �7 �i �� 1�'� ... ��b ,l i .. � � ��rRr� '�.e3+h, *r�°1 ,Y � j, 0.nf 4 da { �c� 5 7 ! Hospitals ,�� No ■ • No Nursing Homes - 4 No ❑Yes ■ No ■ ❑ Yes ►�� MN ❑ No Airports ❑ Yes ►1 No -- ■ ❑ No Comments: * Municipal Liability, except for bodily injury,property damage or personal injury, is automatically provided for the applicant and the other Governmental Body or Entity. If you do not want coverage please notify LMCIT. ** These questions are intended to analyze the coverages provided by the other insurance companies. These other policies must provide bodily injury, property damage or personal injury coverage to the applicant and the other Governmental Body or Entity. • LMCITAPP(11/97)(Rev. 11/03) Page 9 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 2. A. Damages arising out of the following activities are excluded unless such board, commission, • authority, or agency is named in the Declarations, in which case the city will also be covered to the extent of coverage provided under this covenant to the named board, commission, authority or agency for damages arising out of the activities of the respective named board, commission, authority or agency. Please designate the activities you want covered below. B. If the Governmental Body or Entity has purchased coverage elsewhere the City needs to evaluate their exposures and the coverage that they need. 1) Is the city named as an additional insured on the other policy and for what coverage? 2) Does the city want coverage from LMCIT for these activities? PLEASE CONTACT LMCIT FOR ASSISTANCE. ADDITIONAL PREMIUM MAY BE NECESSARY. �� ' } 1 yak ,l YPµ3a air r1 t � '' ' . S r �avD<m rg r Gas Utilities Commission ❑Yes No Questionnaire f X Needed Electric Utilities Commission El Yes 4 No Questionnaire Needed I Steam Utilities Commission ❑Yes VKNo Questionnaire Needed isPort Authority ❑YesNo Need Full Details using & Redevelopment Authority XNo Need Full Details IEconomic Development Authority Yes ❑ No `,�o?S v�Do yNeed Full Details Area or Municipal Redevelopment r]Yes ►': No Need Full Details Authority Municipal Power Agency ❑ Yes 'No Need Full Details IMunicipal Gas Agency ❑ Yes *o Need Full Details - i ciC e. !rt?`�.� --- f y 61,e—,. - ,,,_�•��i"i. .,...�s ,�..e,,: t.. ,,_,,c.<....c.r. li`e4,,✓r:,% . ,.. C t)fl 41.4,1 'rcq / fl,t-eit c011 ,{,71-0,-/-1 c • 4-i' py'a /a,-Z_C.., ,./. 1 � 'Vst..(.� �C✓J .!�'rd.,..vL.•GG s6s!�.!-�r c.�-c�.a/T �.W'�,�[r°,,.,�.,,,��,G.`�L•r...�•t_ .; gLGL."'`"... ✓y'Z.eL•L�(rv,, v.°- • LMCITAPP(11/97)(Rev. 11/03) Page 10 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST mik 3. A. Damages arising out of the following activities are excluded unless the agency or board is specifically named in the Declarations. Please designate the activities you want covered below. B. If the Governmental Body or Entity has purchased coverage elsewhere the City needs to evaluate their exposures and the coverage that they need. 1) Is the city named as an additional insured on the other policy and for what coverage? 2) Does the city want coverage from LMCIT for these activities? L J r �r 9` 9� r ,dF d —� t �. i is a °d e lu a .� ., o�...>n..... _ w.� _s..,_ ,.,,_ .e_ __ . . Welfare or Public Relief Agency ❑Yes ! No Need Full Details School Board ❑Yes g No ■- Need Full Details 4. Does the applicant operate a dump or landfill? v 6 What type of material is deposited there? Is the area fenced to keep out the public when closed? Is the area attended during open hours? io5. Does the applicant own or operate a marina? h.cS' If operated by others, please indicate and advise if the applicant is named as an additional insured on their policy and the policy limits provided. Is coverage desired? Yes ❑ No ❑ If coverage is desired, full details must be submitted. • LMCITAPP(11/97)(Rev. 11/03) Page 11 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 6. Dams classified as Class I or Class II by the Commissioner of the Department of Natural Resources or any dike, levee or similar structure- Failure or bursting 9 is excluded.) A. Age of Dams: Inspected regularly: Yes❑ No ❑ h(a" By Whom: Height of darn above reservoir: Height of dam above the bottom of spillway: Width: Is the dam fenced to keep the public off? Acre feet of water dam has been designed to retain: acre feet B. Age of Dike or Levee: Kota- Height of Dike or Levee: Construction Material of Dike or Levee: Acre feet of water Dike or Levee has been designed to retain: acre feet Who built the Dike or Levee? Is the Dike or Levee inspected regularly? By Whom: 11 7. Describe any large construction projects anticipated for this coming year. 8. Parks and Playgrounds A. Description (including area)of each park or playground: 5 4- `.4 `' 4 B. Description of playground equipment on each: SetmA-t e,44 1414.X.A...#0%.c • LMCITAPP(11/97)(Rev. 11/03) Page 12 of21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 9. Does the applicant operate any aeration devices in the winter to keep an area of local ponds, lakes or • rivers ice free? h6 If so, please give full details and precautions taken. 10. Special Events/Risks Coverage is excluded for several Special Events/Risks. Please review your covenant and contact your LMCIT Underwriter for additional information. Optional coverage may be available. Does the applicant own, operate or sponsor any of the following? If yes, please provide details. A. Automobile, mobile equipment, snowmobile or motorcycle in any racing, pulling or speed or demolition contest or in any stunting event. This would include go cart tracks, mudder courses, • tractor pulls. (Excluded) ❑Yes )INo B. Amusement devices,with a power motor greater than 5 H.P (Excluded) ❑Yes ANo C. Beer booths (Liquor Liability is excluded. Refer for consideration) ❑YesJNo D. BMX tracks ['Yes 1 o E. Climbing Wall ❑Yes NI No F. Dunk Tanks EYes )4No G. Festivals, parades and exhibitions DYes WNo H. Fireworks (Excluded. Refer for consideration.) ❑Yes No I. Rodeos (Excluded) EYes o J. Skateboard Parks ❑Yes o K. Ski jumps, ski lifts and tow ropes ❑Yes No L. Toboggan or Tubing Slides ❑Yes No M. Trampolines EYes to If any of the above are operated by others, please advise if the applicant is named as an additional insured and the policy limits provided. (Continued next page) ID LMCITAPP (11/97)(Rev. 11/03) Page 13 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 10. Special Events/Risks(continued) Details: 11. Firefighters Payroll of paid firefighters: yfa Number of volunteers: N.Ov.Q- Number of fire trucks: hbvQ. Describe any fund raising activities or celebrations by the firefighters or relief associations: 12. EMT's and Paramedics Number of rescue trucks: Number of ambulances Number of emergency runs: Number of convalescent runs: Number of EMT's: Number of EMT-A's: Number of paramedics: Is there radio contact with hospital doctors? Describe any EMT type losses: LMCITAPP(11/97)(Rev. 11/03) Page 14 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • 13. Law Enforcement Total law enforcement payroll: 3 08 S-- �,,,/,,,l�� Ge� / f- ur Number of law enforcement vehicles: "7 oel1''f'ea r, Number of Employees by class: Class A(Full-time): { A(Part-Time): 4 Class B: 0 Class C: Class D: 0 Class E: 0 Class F: 0 Description of classes. A=Armed with arrest power B = Unarmed, no arrest power C= Non-officer employees D =Auxiliary police E=Voluntary unarmed F =Voluntary armed Describe any law enforcement type losses: VvQ^-a" • Describe any jail or detention facilities maintained: Wait Co .jwc t Maximum holding period: CL6 cako,c cQ_ 14. Grandstands and Stadiums A. Number and location of each: t � .?°"i B. Seating capacity: (p0 C. Type of construction: Silit,q wit ONAAJON D. Permanent or temporary: v ..a.AN,QAd 15. Wharf or Docks-Describe: '"Q... S LMCITAPP(11/97)(Rev. 11/03) Page 15 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 16. Street or Road Construction or Maintenance • Annual expenditures: / 0 3 09 / How much work is sublet to others? aa 4%-cit i r- Are Certificates of Insurance obtained indicating ade q uate limits? Is any blasting done? hcS 17. Please describe any contractual agreements the applicant has entered into such as: A. Mutual aid: l J�h i to)Aa.," C 7wv B. Police or fire protection: reu! 't' C. Other. Describe: • 18. Joint Powers Boards are not covered. However, they may be considered for coverage by submitting full i not bound or in effect until you receive • details in a separate application. IMPORTANT! Coverage is no y written acceptance from LMCIT. 19. Do you routinely get Certificates of Insurance from all independent contractors? 20. Does the applicant provide a fire alarm or burglar alarm protection system?` h� If so, please give full details. 21. Any other pertinent information not covered above: w • LMCITAPP (11/97)(Rev. 11/03) Page 16 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST ,t:I7 22. Applicant was created in: (Year)) i 23. Names and official titles of the Members of the Board or council of the applicant: Name Official rvvir e s A-b ra.h eky:-►s O 0-e-U 114 41_1.4 yil 74cLr!< sore • 24. Fiscal Year *Revenue *Expenditure Fund Balance At Year End 20 06 Projected Year If 614, G72-- y# /209 37 o 93, 20 04 Current Budget Vi 72/S;8.22 �� / ?, 17 9 8' 40o, o 3o 20 03 1st Prior Actual 41 02-4't O t 4,451!, rjgZ 55 I( $51 OIL} • 20 0 Z 2nd Prior Actual 414 92, 12.0 4,54 of `1') 3 ` ,, 2 go, 720 20 t7 l 3rd Prior Actual 1 Qeo t 24 417210, 4,1 t G14,001 4(0 *These figures should include all funds including governmental, enterprise, miscellaneous special revenue and debt service funds. If desired, you may send photocopies of appropriate sheets from annual financial report. 25. a. Total amount of outstanding bonds: 1 /G 4 o O ) b. Latest Moody's and/or Standard and Poors'bond rating: ©odt/y� i LMCITAPP(11/97)(Rev. 11/03) Page 17 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 26. Have any of the following situations occurred within the last five years? a. Appropriation or condemnation for which agreed settlements have not been achieved. Dies $No b. Improper or alleged wrongful granting of variances, building permits or similar grants or zoning disputes. (]Yes 'No c. Wrongful or alleged wrongful approval of building plans, designs or specifications. DYes No d. Wrongful or alleged wrongful approval of building construction. DYes VNo e. Allegation of unfair or improper treatment regarding employee hiring, remuneration, advancement or termination of employment. DYes ..54No f. Disputes involving integration, segregation, discrimination or violation of civil rights. DYes No g. Any grand jury indictments of any public officials. DYes No h. Assault and battery claims made against the municipality or its officials. DYes No i. Any riot or civil commotion in the past five years. DYes No j. Any losses or claims occurred involving contractual disputes. DYes No • 27. Land Use Liability Number of building permits issued: 11 7 z Number of variances: Granted / Denied (, Number of conditional use permits: Granted 2' -Denied O 28. H the City submitted their Comprehensive Plan to the Metropolitan Council for review and comment? Yes ❑No Has the Metropolitan Council reviewed the plan and made their comments? Yes :No Are you a participant in the Metropolitan Council Livable Communities Program? Yes ❑No What year did you join? • LMCITAPP (11/97)(Rev. 11/03) Page 18 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 29. Please list the additional covered parties required. • �a f' t v r,.1`�,� r >Fr L�e 7i�.�, , n, g � Et l rl+ r bd e ��;��r P'- ADDITIONAL COVERED NAME ADDRESS PARTIES INTEREST • 30. Contracts with a railroad and contracts with the contractor performing the actual railroad construction p roject needs special attention. Please provide a copy of the contract to LMCIT. This does not apply to easement or side track agreements. Please contact LMCIT beforeyou sign a construction agreement with a railroad or the contractor that is performing the actual railroad construction project, • LMCITAPP(11/97)(Rev. 11/03) Page 19 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST AUTOMOBILE LIABILITY AND PHYSICAL DAMAGE • Applicant: C e ci 04. ri)cv ( 4.44_110-✓y 1. COVERAGES: A. Liability: Limit: $1,000,000. Combined Single Limit on Bodily Injury and Property Damage '\C, PLEASE INDICATE ALL UNREGISTERED VEHICLES ON THE ATTACHED SCHEDULE! PLEASE CLEARLY IDENTIFY,OR PROVIDE A LIST OF ALL UNMARKED POLICE VEHICLES! B. Do you want PIP coverage on the unregistered vehicles?v..* ❑Yes ❑No This is an optional coverage. C. Uninsured and Underinsured Motorists The standard limit is$50,000. Indicate limit desired. (1) ❑ $50,000. Uninsured and Under insured Motorist Limit* or (2 ' $1,000,000. Uninsured and Under insured Motorist Limit (3) Do you want UM/UIM coverage on the unregistered vehicles?ir■k' ❑Yes ❑No This is an optional coverage.. D. Automobile Physical Damage: • The separate"comprehensive"and"collision"coverage options have been replaced by the new"auto physical damage"coverage that covers both collision and comprehensive. 2. Applicants have the option to make their LMCIT Liability Coverage primary for vehicles used by specified individuals or groups in specified circumstances. Plea a dicate if you want this optional coverage and provide additional information requested. ['Yes No If yes, please indicate type of individuals or groups: If yes, please indicate number of individuals: 3. VEHICLE SCHEDULE Refer to the LMCIT Auto Coverage Changes bulletin included in your renewal packet. The applicant needs to submit an accurate listing of vehicles for the renewal. The applicant's premium for auto liability and physical damage coverages for the entire year will be based on the schedule of vehicles the applicant reports at renewal. A. All vehicles are covered for liability. B. All vehicles are covered for physical damage, unless you indicate otherwise. C. The listing of vehicles should include only those trailers with a load capacity greater than 2000 pounds. Smaller trailers are now automatically covered for liability and physical damage. D. Replacement cost is available for an additional premium on Fire Trucks and other high valued vehicles aped 10 years or less. (Indicate unit number and replacement value). E. Replacement cost may be considered for an additional premium on units aged 10 years or more with proper documentation of the maintenance history. F. Please indicate color of Fire Trucks 1=Lime Yellow; 2 =Red; 3=All Others •(The attached computer printout provides the most current Schedule. 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I. n f\ n O O O O O I- CI J .i N N CO O CO O CO .1 N .1 .I 2 = • 0 'O o in in 1.1 M en so to O 10 N W U > UI in N 17 in 17 17 01 N N in Uf N W N N N N N N N N N N N N N U J a Lii C W I- W < t0 U in O O O O O O O O O O O O O O W = a a a a a a a a a a a a a 2 J M • O in in S W U J V C W O J O U H 0 C = W > W J > U O .0 10 10 V .1 .0 a < 10 .0 '10 40 10 .1 I- 2 01 01 01 O O O O O .+ .1 .+ .1 .I W in in N O O 0 O O 10 10 10 0 10 O U > CT O Q 10 0 0 10 10 10 10 10 10 10 W. J < O O O O O O O O N I- I- I- M H M < M I- I- I- 0- I- U N C C C C C M N M N 0 J O O O O O O O O O O O O O C w W W W 1- F 1- H 1- W W W W W F o a a a u u U u u a a a a a O x x x .1 w x x x x x w Z W W W > > > > > W W W W W C i. LL 2 W Z Z 2 2 Z O < O O O O O I- U U U U U O W U O O O o O O O O O O O O O O < C O C O C O C O C O 0 CL C C C C C C C I- 0 O O O O O Z I- LL U. LL LL LL LL LL LL LL LL -LL LL LL = W w C 01 M N 01 01 1.1 1.1 N Y Y a < Y < O < O O O O O O O O O O O O O J O W O O O O O O O O O O O O O 6 S > N N N N N N N N N N N N N W +*r W U O N N S O O O W ..4 * O > N U In H N J U O S a u U- 0 1- • U H a .1 .0F i .4• i W < S Z N 2 O O C • W < 1 a a 0 • V 2 Y Z • O 1-1 O LEAGUE OF MINNESOTA CITIES INSURANCE TRUST UNREGISTERED VEHICLE SCHEDULE 1 2 3 4 - 5 6 7 8 _-- 9 10 -- 12 13 �-- 14 15 16 ■ -- 17 _-- - 18 --- _ 19 20 21 �-- - 22 � -- 23 24 --- - 25 �-- - LMCITAPP(11/97)(Rev. 11/03) Page 21 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PUBLIC EMPLOYEE EISHONESTY OR PUBLIC EMPLOYEE FAITHFUL PERFORMANCE COVERAGE APPLICATION • Limit of Coverage Per Occurrence: (Deductible) • Bond—Employee Dishonesty Coverage: $ t1( O I OOG• (Standard) • Bond—Employee Faithful Performance Coverage: $ 100 ` 0 00 • (Standard) • Option: The applicant may choose to have employee dishonesty or faithful performance coverage for specified positions. Please contact your LMCIT underwriter for additional information. KC AUDITS: FREQUENCY: BY WHOM? CPA _ X STAFF AUDITOR 0w4`^M-CA OTHER(explain Fully) DATE OF LAST AUDIT: DISCREPANCIES iilt,d'ES NO ('�,. '3 1 - 0 j (If YES,submit copy of au it or auditors comments.) LOSS HISTORY: (LAST 5 YEARS) WILL THERE BE A SUBSTANTIAL INCREASE IN THE NUMBER OF EMPLOYEES DURING THE TERM OF THIS BOND? INTERNAL CONTROLS: 1. ARE BANK ACCOUNTS RECONCILED AT LEAST MONTHLY? X YES ❑ NO • 2. IS THE PERSON WHO RECONCILES PROHIBITED FROM MAINTAINING BANK ACCOUNT RECORDS? RYES ❑ NO 3. ARE ALL PERSONS HAVING AUTHORITY TO MAKE BANK DEPOSITS OR WITHDRAWALS PROHIBITED FROM EITHER MAINTAINING RECORDS OR RECONCILING THE BANK ACCOUNT? XYES ❑ NO 4. IS COUNTERSIGNATURE OF ALL CHECKS REQUIRED? \YES ❑ NO ADDITIONAL COMMENTS: • LMCITAPP.PEB(11/97)(Rev. 11/03) Page 1 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST CLASSIFICATION OF EMPLOYEES BY DUTIES OR RESPONSIVILITIES • This classification under Class A, B and C constitutes the cities personnel as of the date of this application and should include Mayor and Council members. CLASS A EMPLOYEES All Executive Administrative Judicial and Supervisory officials,Department and Division Heads and Assistant Department and Division Heads.All Police Officers"and all officials and employees whose principal duties require them to: 1.) Handle,receipt for,or have custody of money,checks or securities,or account for supplies or other supplies or other property,authorize(or make appropriations for) expenditures;approve,certify,sign or countersign checks,drafts,warrants,vouchers,orders or other documents providing for the paying over or delivery of money, securities,supplies or other property,or serve process,or 2.) Maintain or audit accounts of money,checks,securities,time records,supplies or other property,or take physical inventories of money,checks, securities,supplies or other property. "Patrolmen are classified as"A"Employees under"Faithful Performance"Coverage but are classified as"C"Employees under'Dishonesty'Coverage. POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS �r /I•ccnkwtre mot" .,i AI r'e P�bI��tJI<s17,`r _ fgrd r ..sp O I A14 1 J.— CLASS B EMPLOYEES All personnel whose principal duties consist of: 1. Inside or outside clerical activities; 2. Office work such as stenography,typing,filing,switchboard operation,business machine operation,etc.; 3. Operation of vehicles transporting passengers for cash fare or tickets. POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS /,1:r-r: er 1 CLASS C EMPLOYEES All personnel whose principal duties consist of: 1. Skilled or unskilled labor and craftsmanship; 4. Any teaching capacity in the field of education; 2. Solely the mechanical operation of automotive equipment 5. Outside or field work of a non-clerical nature; 3. Non-clerical activities of the medical or nursing profession; 6. Patrolmen under the"Dishonesty"Coverage POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS re. 2' - v.b 1. 4t7 o"!<S • - LMCITAPP.PEB(11/97)(Rev. 11/03) Page 2 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST EQUIPMENT BREAKDOWN APPLICATION • APPLICANT: C't ' 0 -- � 'kc 4 ' INSPECTION CONTACT AT CITY: ()JAI i"kok Or TELEPHONE #: (- 439r 439 AGENT'S NAME: Ott, "Ti nh c' TELEPHONE#: 6,5 ( - 4(e it- 3 33 3 COMPREHENSIVE (INCLUDING PRODUCTION MACHINES) NON-REFERRAL OCCUPANCIES ONLY LIMITS: $ Limit any one accident, is the Property General limit of Coverage per Occurrence or $60,000,000 whichever is less any one accident $ 5,000,000 Business Income and Extra Expense $ 100,000 Service Interruption at-e $ 100,000 Perishable Goods vt' $ 100,000 Data Restoration $ 100,000 Demolition and Increased Cost of Construction $. 100,000 Expediting Expenses • $ 100,000 Pollutants $ 100,000 CFC Refrigerants $ 50,000 Ice Buried Piping 1. Does the applicant currently have Boiler& Machinery coverage? ❑ Yes No 2. Name of current Boiler& Machinery carrier Expiration Date: 3. Has the applicant had any boiler and machinery breakdowns in the past 3 years? 'Yes ❑ No If yes, please provide description and amount. amp �a c.t 14-ui'NIcc c-to /'h �/ KKK Pee r k /1 t ; "$'7.? Rs- (Poe a gee& `/`..e...t ��.�n> e.a.e . r� re d te r' IP r 1'C sift 3.L.crO COO g") • 4. Desired Deductible: LMCITAPP.EQUIPBRKDWN(11/03) Page 1 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 5. REFERRAL OCCUPANCIES(Limited Coverage) • Important: If the applicant has any of the following exposures,further analysis may be required by LMCIT. Coverage for any of these exposures cannot be bound unless approved by LMCIT. Each exposure must indicate a yes or no response. Special conditions, endorsements, limits and deductibles may apply. Please contact your LMCIT underwriter. A. Refuse burning facility(HEM) ❑Yes'No B. Equipment for recovering methane or other gases from a sewage treatment plant or landfill, or any other system for producing industrial gases (HBG) ❑Yes No C. Hospital/Clinic equipment listed below(HBH) ❑ Yes No 1. CT Scanner ❑ Yes ❑ No 2. MR1 Unit ❑ Yes ❑ No 3. PET 0 Yes 0 No • 4. Linear Accelerator ❑Yes ❑ No 5. Lithotripter ❑ Yes ❑ No D. Steam or hot water district heating system (HBM) ❑Yes,rNo E. Electrical Generating Equipment )Yes ❑ No Type: XiDiesel (HBD) ❑ Other(HBE), describe This does not include emergency back-up generators that serve only a single building or function and are not part of a municipal utility. Special Note: LMCIT can provide equipment breakdown coverage for diesel generating equipment,but not for other types of electrical generation equipment such as steam or gas turbines,wind turbines,or hydro-electric facilities. If the utility has both diesel and other types of equipment, the entire risk must be placed with an equipment breakdown insurance company. i LMCITAPP.EQUIPBRKDWN (11/03) Page 2 of 2 r LEAGUE OF MINNESOTA CITIES INSURANCE TRUST EXCESS LIABILITY APPLICATION III Applicant: l i 41 a ` AL -4% � Date: G"30 - 65 0 , Limit of excess coverage desired: 1"i��tcS� u v�-� $1,000,000 ❑ $2,000,000 El $3,000,000 `'q2 884 207 $4,000,000 ❑ $5,000,000 / Do you wa t t e Excess to apply to the Uninsured and Underinsured coverage provided by the primary covenant? Yes ❑ No If yes,the automobile UM/UIM limits must be$1,000,000. The Excess Covenant does not automatically apply to liquor Hal).ity. Do you want the excess to apply to liquor liability'? ❑Yes No Special Note: The liquor liability primary limits must be $1,000,000. Employers Liability: Carrier: LM( t1 Limits: k i 0 Ot) I 000 - Policy Number: '''‘El-- Policy Period: —7 in ( OS "' 1 � 1 (oc, 11 Does applicant now have or contemplate any exposure under: (If yes, attach sheet with payroll figures.) • (a) Jones Act or Admiralty Jurisdiction ❑Yes kNo (b) Federal Railroad Employees Act ❑Yes ,No (c) Federal Longshoremen's& Harbor Workers Act ❑ Yes )No To what extent does applicant have primary insurance to cover these exposures? V■,f o IF THIS IS A RENEWAL, PLEASE INDICATE IF RENEWAL IS TO BE BOUND: RYES ❑ NO Note: Coverage is excess of LMCIT coverages only. Some of the coverage is not follow form. • LMCITAPP.12(11/97)(Rev. 11/03) Page 1 of 1 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST SUBMITTED BY: L44diila/'k .-,L-rts r'Gc roc ,c4c1'(/✓r� S • PRODUCER: / t'7 %�;p(��'/1 ADDRESS: 23 2.- &.DLi-fh 1.1,./c' t �.c .t v✓- s7L`L- <`�_ ,1 MJ SSV2 1 APPLICATION FOR OPEN MEETING LAW DEFENSE COST REIMBURSEMENT AGREEMENT APPLICANT'S INSTRUCTIONS: 1. Please answer all questions. If the answer is NONE, please state NONE. 2. If space is insufficient to provide a complete response, attach a separate sheet. 3. The application must be signed by an authorized representative of the City. Special Note: Please answer all questions. These questions are intended to provide general information only. The information provided will also be used for a proactive loss control procedure if needed. APPLICANT • 1. Name of city or other public entity whose city officials are to be covered under the Agreement. 2. Principal Address: / 9- 4�t/c Pu r lc 3 I 'd. I 3. If Joint Powers entity, identify participants: YP P (1)/4 • LMCITAPP.OML(11/97)(Rev.11/03) Page 1 of 3 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST CLAIM HISTORY • List incidents of threatened or actual open meeting law litigation involving city related individuals in the last five years. For each incident give its approximate date and its resolution, including the penalty imposed, if any, and the amount of attorneys fees incurred in defending the incident. q 2. Are you presently aware of any other incidents or situations which may result in an open meeting law claim or litigation against city related individuals? ❑ YES NO If YES, give details: 3. What action has been taken to prevent future incidents or claims? • LMCITAPP.OML(11/97)(Rev.11/03) Page 2 of 3 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST OPEN MEETING LAW • QUESTIONNAIRE 1. Description of orientations and/or training provided for all elected officials (GTS programs, League programs, Handbook for Minnesota Cities, loss control seminars ...)on the subject of the open meeting law: S' C f 4.st_ tre. (,c.r 2. Have all new members attended the League Conference for Newly Elected Officials? EYES ❑ NO 3. Do all officials understand the Open Meeting Law and the Cities'compliance procedures? YES ❑ NO 4. Description of method of documenting official meetings (written, audio, video, ...): • (Ai r " td 5. Does legal council attend all official meetings?A'YES ❑ NO If no, describe service relationship with city attorney. 6. Is education provided for the elected officials in the proper policy and procedures? a) Land use decision making: .YES ❑ NO b) Employment practices: KYES ❑ NO 7. Please indicate the percentage of reimbursement of defense costs. ❑ 80% p(100% O BY: /0/1;g/..044-44C- (Signature and Title of Authorized Representative) LMCITAPP.OML(11/97)(Rev.11/03) Page 3 of 3 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • SUBMITTED BY: PRODUCER: ADDRESS: ZIP: APPLICATION FOR MINNESOTA PETROFUND SUPPLEMENTAL REIMBURSEMENT AGREEMENT APPLICANT'S INSTRUCTIONS: 1. Answer all questions. If the answer is NONE, please state NONE. 2. If space is insufficient to provide a complete response, attach a separate sheet. • 3. The application must be signed and dated by an authorized representative of the City. 4. PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION. APPLICANT 1. Name of City or other public entities to be covered under the Agreement. • LMCITAPP.MPRAAP(11/97)(Rev. 11/03) Page 1 of 6 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 2. Principal Address: 3. If Joint Powers entity, identify participants: • 4. Designate the public official primarily responsible for environmental protection: NAME: TITLE ADDRESS: TELEPHONE • TANK SITE INFORMATION 1. Please list and describe all active and inactive underground and above ground storage tanks on the attached storage tank schedule. This list must include all tanks acquired through the Housing and Redevelopment Authority and the Economic Development Authority or any similar department/agency. 2. Are all tanks registered with the Minnesota Pollution Control Agency? ❑ YES ❑ NO If NO, please explain below: S LMCITAPP.MPRAAP(11/97)(Rev. 11/03) Page 2 of 6 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • 3. Do all tanks including piping meet all local storage tank regulations? ❑ YES ❑ NO If NO, please explain below: 4. Do all tanks including piping meet all state storage tank regulations? ❑YES ❑ NO If NO, please explain below: • 5. Do all tanks including piping meet all Federal storage tank regulations? ❑YES ❑ NO If NO, please explain below: 6. Have you received any complaint or notice that any of your tanks including piping are leaking or have you any other indication that any of your tanks including piping are leaking? ❑ YES ONO If YES, please explain below: • LMCITAPP.MPRAAP(11/97)(Rev. 11/03) Page 3 of 6 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST CLAIM HISTORY • 1. List individual petroleum tank release incidents or claims and damages/expenses: Describe Injury Amounts Paid Date of Incident or Damage or Reserved Location 2. Identify your tank sites that have been the subject of environmental litigation,claim or administrative prosecution or complaint. Please give details: • 3. Are you aware of any other incidents or conditions which may result in a claim against you? ❑YES ❑ NO If YES, give details: 4. Have you ever performed any remedial clean-up actions at any of your tank sites? ❑YES ❑ NO If YES, give details: • LMCITAPP.MPRAAP(11/97)(Rev. 11/03) Page 4 of 6 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • The undersigned authorized representatives of the A pp licant represents to the best of his/her knowledge the statements herein are true, and it is agreed that this application shall become incorporated as a part of the Minnesota Petrofund Supplemental Reimbursement Agreement if accepted by LMCIT. LMCIT is hereby authorized to make any investigation and inquiry in connection with this application, as it deems necessary. Dated at this day of ,20_. (Name of Applicant) BY: (Signature and Title of Authorized Representative) • I • LMCITAPP.MPRAAP(11/97)(Rev. 11/03) Page 5 of 6 • -o H • Qa) c 0 2 L c 0 U 9 0 a) to c 0 W F (,� o 0 -� Q w Z w — cn W . Q U 1- • W to Q W Z Z 0 ° c 2 tj a ti `'= - O aN W — o C Q H W J r^ N r:4 n O, y 4: a, y U Q W — O E as • c; c5 U o cLi o J 0 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • LIQUOR LIABILITY APPLICATION APPLICANT: AGENTS NAME: TELEPHONE NUMBER 1. Effective Date: Name of Licensee: License# 2. Limits of Liability:$ Per Claim $ Annual Aggregate 3. Receipts: Alcoholic Beverages$ (Past 12 months) $ (Estimated next 12 months) 4. List of locations covered and their operations: Location: Operation: Location: Operation: 5. Underwriting: (A) Has the applicant or any employee,officer or licensee incurred any claim for liquor liability in the past 5 • years? ❑Yes ❑ No If yes,explain: Is the applicant aware of any incidents which may lead to a claim? ❑Yes 0 No If yes,explain: (B) Have there been any fights or assaults inside or outside the locations among patrons in the past year? ❑Yes ❑ No If yes,give details: Have there been any incidents of any employee,officer,or licensee using reasonable force to remove patrons? ❑Yes ❑ No If yes,explain: (C) Does the applicant provide for their employees to receive formal training in the following areas? Operations? ❑Yes ❑ No Handling of minors? ❑ Yes ❑ No Handling of intoxicated customers? ❑Yes ❑ No How often is the training done? By whom? Does the applicant provide any additional training? ❑Yes ❑ NO If yes,explain: • LMCITAPP.LLC(11/97)(Rev. 11/03) Page 1 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • (D) Has the applicant,or any owner,partner,officer,member of licensee ever had a license revoked, refused,or suspended? ❑Yes ❑ No If yes,give details: (E) Previous Carrier: Exp. Date: Premium Policy Number: Limit of Liability (F) Years in business at this location under current ownership: If under 2 years,give previous experience: (G) Has applicant or employee ever been fined or cited for violations of a law or ordinance relating to sales of alcohol?(After hours,minor,etc.) ❑Yes ❑ No If yes,explain: (H) Normal Open/Closing hours: Mon-Thurs Fri Sat Sun (I) Does applicant have entertainment? ❑Yes ❑ No If yes;explain: 4110 (J) What is the turnover of bartenders? (K) Is there a documentation procedure in place for incidents? ❑Yes ❑ NO If yes,explain: 6. Do you have any special events sponsored and controlled by the liquor store? ❑Yes ❑NO If yes,please describe: Coverage is excluded. An endorsement is necessary. Please let us know if you want coverage. 7. Do you have any other special events that is not sponsored or controlled by the liquor store? If yes,explain: Coverage is excluded. An endorsement is necessary. Please let us know if you want coverage. 8. Receipts On-Sale Receipts Off-Sale Receipts Special Events Number of Days • By: (Signature and Title of Authorized Representative) LMCITAPP.LLC(1 1/97)(Rev. 11/03) Page 2 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • NO FAULT SEWER BACK-UP COVERAGE APPLICATION APPLICANT: AGENTS NAME: TELEPHONE NUMBER 1. Inspection and maintenance program Does the applicant have an inspection and maintenance program? ❑Yes❑ No Please describe briefly or attach a copy of the program. 2. Problem area identification procedures Does the applicant have in place procedures for identifying and abating problem areas in the system that may require more frequent inspection or cleaning? ❑Yes ❑ No Please describe briefly. • 3. Emergency response system Does the applicant have a procedure for providing 24-hour/7 day emergency response to sewer back-ups? ❑Yes ❑ No Please describe briefly. 4. Inflow and Infiltration Procedures(Storm water getting into the sanitary sewer system) Does the applicant have an active plan to minimize the effect of storm water getting into the sanitary sewer system? ❑Yes❑ No Please describe briefly. • LMCITAPP.SEWERBU(11/00)(Rev. 11/03) Page 1 oft LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • 5. Documentation Does the applicant maintain written records of its normal maintenance and inspections of the sewer system? 0 Yes 0 No Does the applicant maintain written records for its cleaning and inspection of problem sewer lines? ❑Yes 0 No 6. Planning Does the applicant have capital improvements planning in place to remedy any ongoing problems with its sewer system? 0 Yes 0 No Please provide details including a description of the plan, availability of financial resources and timetables. Special Note: No fault Sewer Back-up Coverage cannot be bound until the applicant has met the underwriting criteria and has passed a No Fault Sewer Back-up Resolution. • By: (Signature and Title of Authorized Representative) • LMCITAPP.SEWERBU(11/00)(Rev. 11/03) Page 2 of 2 g " `�,i ( ACDRD DATE(MM/DDmr) c �.,. w. '-" ; .., 1 ;., 07/01/05 „ . � ,,,,4*-. ,: :. Via. PRODUCER PHONE APPLICANT (A/C,No,Est): 651-464-3333 (First Fps NO. Named (A/C,No,Ext): insured) City of Oak Park Heights Landmark Insurance Services EFFECTIVE DATE EXPIRATION DATE PAYMENT PLAN AUDIT 2 outh Lake Street X DIRECT BILL F t Lake MN 55025 07/01/04 07/01/05 AGENCYBILL ANNUAL Landmark Insurance Services FOR COMPANY CODE: 5513 I SUB CODE: USE ONLY AGENCY CUSTOMER ID MAKE: CHEV TYPE: ,.PICKUP „.•, a VEH# YEAR SYM/AGE COST NEW 1 1987 MODEL: 1 TON 1 -,, V.I.N.: 6960 $ y i{l TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM CITY,STATE,ZIP V WHERE GARAGED DRIVE TO WORK/SCHOOL USE COMM'L COVERAGES ADD'L PIP X MOTORS F LSP DEDUCTIBLES X ACV X COMP C SPEC UNDER 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING FT COMP AA ST AMT $ 500 15 MILES OR OVER FARM SERVICE X PIP X MOTOR SPEC OF L FTW X LOLL $ $ 500 COLL VEH# ' YEAR MAKE: Chet/ TYPE SYM/AGE COST NEW 9 1997 MODEL: Pickup V•I•N•: 1GCGK24R3VZ216571 $ 21700 TERR GVW/GCW CLASS SIC FACTOR 'SEAT CP RADIUS FARTHEST TERM CITY,STATE,ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL USE COMM'L CHEC ADD'L PIP X UNDRINS F LSP DEDUCTIBLES X ACV COMP SPEC COVERAGES MOTOR C OF L UNDER 15 MILES PLEASURE RETAIL X LIAB MED PAY TOWING FT X COMP AA ST AMT $ 500 & — 15 MILES OR OVER FARM SERVICE X PIP X MOTOR C OF L FTW X COLL $ $ 500 COLL VEH# YEAR MAKE: FORD TYPE CAR SYM/AGE COST NEW 6 1995 MODEL: CROWN VIC V.I.N.: 1817 $ TERR GVW/GCW CLASS SIC ' FACTOR SEAT CP RADIUS FARTHEST TERM CITY,STATE,ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL USE COMM'L COVERAGES ADD'L PIP X MOTOR F LSP DEDUCTIBLES X ACV X COMP C OF L DER 15 MILES PLEASURE RETAIL TOWING X LIAB MED PAY &LABOR FT X COMP AA STAMT $ 500 ILES OR OVER FARM SERVICE X PIP X MOTOR SPEC OF L FTW X COLL $ $ 500 COLL BODY SYM/AGE COST NEW VEH# YEAR MAKE: Chev TYPE: 1990 MODEL: pickup V.I.N.: 2GCEK19K4L1245936 $ TERR GVW/GCW CLASS ' SIC ' FACTOR SEAT CP RADIUS FARTHEST TERM CITY,STATE,ZIP Oak Park Heights WHERE GARAGED DRIVE TO WORK/SCHOOL USE COMM'L COVERAGES ADD'L PIP �[ MOTOR F LSP DEDUCTIBLES ACV COMP C OF L TOWING UNDER 15 MILES PLEASURE V RETAIL X LIAB MED PAY &LABOR FT COMP AA ST AMT $ UNINS SPEC 15 MILES OR OVER FARM SERVICE X PIP X MOTOR C OF L FTW COLL $ $ COLL VEH BODY SYM/AGE COST NEW EH# YEAR MAKE: Ford TYPE: 1998 MODEL: Crown Vict V.I.N.: 2FAFP71W5WX145018 $ TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM CITY,STATE,ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL USE CHEC T - UNDRINS DEDUCTIBLES SPEC COMM'L COVERAGES ADD'L PIP X MOTOR F LSP ACV COMP C OF L TOWING UNDER 15 MILES _ PLEASURE ` RETAIL X LIAB MED PAY &LABOR ^ FT X COMP AA _ STAMT $ 50 0 UNINS SPEC 15 MILES OR OVER FARM SERVICE X PIP X MOTOR C OF L FTW X COLL $ $ 500 COLL VEH# YEAR MAKE E: Ford BODY SYM/AGE COST NEW 4X4W/PLOW 011 1999 MODEL: F350 V.I.N.: 1FTSF31 7XED4350 $ 26800 L TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM CITY,STATE,ZIP Oak Park Heights MN WHERE GARAGED 50 DRIVE TO WORK/SCHOOL USE COMM'L CHEC ADD'L PIP X MOTOR _ F LSP DEDUCTIBLES X ACV X I COMPy C OF L COVERAGES TOWING UNDER 15 MILES PLEASURE RETAIL LIAB MED PAY &LABOR FT X COMP AA ST AMT $ 500 15 MILES OR OVER FARM SERVICE X PIP X MOTOR C OF L FTW X COLL $ $ 500 COLL BODY VEH# YEAR MAKE: Ford Dump mp Truck SYM/AGE COST NEW 1999 MODEL: F550 w/plo V.I.N.: 1 FDAF57 YE I231 $ 39518 L TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM wTM T ARAGED Oak Park Heights MN 50 C UNDRIN SPEC D WORK/SCHOOL USE DEDUCTIBLES COMM COMM'L COVERAGES i ADD'L PIP }t MOTOR F LSP —X_ACV I COMP C OF L TOWING UNDER 15 MILES PLEASURE RETAIL LIAB MED PAY FT COMP AA STAMT $ X — SEC x 5(10 - 15 MILES OR OVER FARM SERVICE PIP UNINS OR C OF L FTW COLL $ $ COLL RIV .. I.µ17 fir /.. ; `., H ,, .y„.� ; .: \ ,, , n, / �L �. .s ,"::::0.!:. `,`..-W” ��iq'�'' 4 � t: mxs' �� -�� i. r 'Li �s�its � �i�Y��S�>»� �\�a����� '��" - ': - fit_.,,,, ';. ?'a.. \ . "„Sr;a,,,, .. R� , ... ... _., .-� VEH# YEAR MAKE: GMC TYPE police car SYM/AGE COST NEW 1999 MODEL: Yukon 4x4 v.I.N.: 1GKEK13R2XJ761704 $ 28700 TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS ' FARTHEST TERM CITY,STATE,ZIP Oak Park Heights MN WHERE GARAGED 50 D WORK/SCHOOL USE CHECK ADD'L PIP X UNDRINS F LSP DEDUCTIBLES X ACV COMP SPEC X COMM'L COVERAGES MOTOR C OF L UNDER 15 MILES PLEASURE RETAIL X LIAB MED PAY TOWING FT X COMP AA ST AMT $ &LABOR 15 MILES OR OVER FARM SERVICE X PIP X MOOR C OF L FTW X COLL $ $ COLL VEH# YEAR MAKE: Ford 16'YOPE: Police car SYM/AGE COST NEW 013 2000 MODEL: Expedition V•I•N•: 1FMPU16LXYLB36653 $ 26695 I ' TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM CITY,STATE,ZIP Oak Park Heights MN WHERE GARAGED 50 DRIVE TO WORK/SCHOOL USE COMM'L CHECK ADD'L PIP UNDRINS F LSP DEDUCTIBLES ACV COMP SPEC X COVERAGES MOTOR C OF L UNDER 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING& FT COMP AA ST AMT $ 15 MILES OR OVER FARM SERVICE PIP MOTOR C OF L FTW COLL $ $ COLL VEH# YEAR MAKE: CHEV TYPE SYM/AGE COST NEW 010 1995 MODEL: Caprice v.LN.: --4521 $ TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM CITY,STATE,ZIP WHERE GARAGED SPEC COMM'L COVERAGES UNDOIRS F LSP DEDUCTIBLES x ACV }[ COMP C OF L DRIVE TO WORK/SCHOOL USE ADD'L PIP X MOTOR UNDER 15 MILES PLEASURE RETAIL X LIAB MED PAY TOWING FT X[ COMP AA ST AMT $500 &LABOR 15 MILES OR OVER J FARM SERVICE X PIP X MOTOR C OF L FTW X COLL $ $500 COLL VEH# YEAR MAKE: CHEV BODY TYPE: SYM/AGE COST NEW 011 1996 MODEL: Blazer V.I.N.: --1236 $ ' TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS ' FARTHEST TERM CITY,STATE,ZIP WHERE GARAGED .ii DRIVE TO WORK/SCHOOL USE CHECK gDD'L PIP UNDRINS F LSP DEDUCTIBLES X ACV X COMP C OF L COMM'L COVERAGES X MOTOR UNDER 15 MILES PLEASURE RETAIL �( LIAB MED PAY &,ABOR FT ]{ COMP AA ST AMT $500 15 MILES OR OVER FARM SERVICE X PIP X MOTOR C OF L FTW X COLL $ $500 COLL VEH# ' YEAR BODY SYM/AGE COST NEW MAKE: TYPE: MODEL: V.I.N.: $ TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM CI ATE,ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL USE COMM'L CHECK ADD'L PIP UNDRINS F LSP DEDUCTIBLES ACV COMP SPEC COVERAGES MOTOR C OF L UNDER 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING FT COMP AA ST AMT $ &LABOR 15 MILES OR OVER FARM SERVICE PIP MOTOR C OF L FTW COLL $ $ COLL VEH# YEAR BODY SYM/AGE COST NEW MAKE: TYPE: MODEL: V.I.N.: $ TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM CITY,STATE,ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL USE COMM'L CHEC< ADD'L PIP UNDRINS F LSP DEDUCTIBLES ACV COMP SPEC _ COVERAGES MOTOR C OF L UNDER 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING FT COMP AA ST AMT $ &LABOR _ 15 MILES OR OVER FARM SERVICE PIP MOTOR C OF L FTW COLL $ $ COLL VEH# YEAR BODY SYM/AGE COST NEW MAKE: TYPE: MODEL: V.I.N.: $ TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM CITY,STATE,ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL USE COMM'L CHEC ADD'L PIP UNDRINS F LSP DEDUCTIBLES ACV COMP SPEC COVERAGES MOTOR C OF L UNDER 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING FT COMP AA ST AMT $ &LABOR 15 MILES OR OVER FARM SERVICE PIP MOTOR SPEC OF L FTW COLL $ $ COLL VEH# YEAR BODY SYM/AGE COST NEW MAKE: TYPE: MODEL: V.I.N.: $ TERR GVW/GCW CLASS SIC FACTOR 'SEAT CP RADIUS FARTHEST TERM CITY,STATE,ZIP WHERE GARAGED CHEC UNDRINS DEDUCTIBLES SPEC DRIVE TO WORK/SCHOOL USE COMM'L COVERAGES ADD'L PIP MOTOR F LSP ACV COMP C OF L UNDER 15 MILES PLEASURE RETAIL LIAB — MED PAY TOWING FT COMP AA ST AMT $ &LABOR _ SMILES OR OVER FARM SERVICE PIP MOTOR C OF L FTW COLL $ $ COLL E! 1 j ii O 2 . gell,., -� k 92y�.5-7 V-712,73;6?-707 2 2 YS3. 71 2 5--e7G ,Y‘., ige"( , g73q3 iF I �, . z. � ^ 9 0 • 1 — / ' . / 2?, i J L '/Isct-,`p,/ G'G ri 11 75 1) i,� films ,f- /. B-z9-D I L71-46, 4-d-,-,,,/4-7,' /5 o ...moo, oa U KrIC S e 9? 5-5'0 i a.s,_ c,„ ,..)D t, , Ic.,,.,‹A. , ,,--, 06-0 `64e, oo, a S --4 J/ oy/ 0,s-c., 0 s 0 g. <35‘ n - Page 1 of 2 F Judy Hoist _. _.._ • From: Julie man Sent: Wednesday, July 06, 2005 8:39 AM To: Judy Hoist Subject: RE: Land Use Liability Morning Judy - In 2004 approvals were granted to 8 Conditional Use Permit and 4 Variance requests. None were denied. N Julie Original Message From: Judy Hoist Sent: Wednesday, July 06, 2005 7:52 AM To: Julie Hultman Subject: RE: Land Use Liability 2004 is correct. Thanks, Judy From: Julie Hultman Sent: Tuesday, July 05, 2005 7:30 PM To: Judy Hoist Subject: RE: Land Use Liability Hey Judy - No problem with the short notice. Just a good thing that I am back on Tuesday the 6th. Can I assume this is for the year 2004? I am going to proceed under that assumption unless otherwise directed by you and will get on it a/s/a/p. :) Julie Original Message From: Judy Hoist Sent:Tue 7/5/2005 11:57 AM To: Julie Hultman Cc: Subject:Land Use Liability Julie, I need some info from you by Wednesday, July 6th. I'm doing the LMCIT Insurance Premium paperwork and they need it by the 12th. I just received it Friday July 1st and will be on vacation starting Thursday, so I will have to get this in the mail to them by Wednesday the 6th. Sorry it's short notice. What I need is: 7/6/2005 Page 2 of 2 1. Number of variances: Granted Denied • 2. Number of conditional use permits: Granted Denied Thanks for your help. Judy • • 7/6/2005 • City of Oak Park Heights 14168 Oak Park Blvd. N•Box 2007•Oak Park Heights,MN 55082•Phone(651)439-4439•Fax(651)439-0574 January 314,2005 MEMO TO: Tom Ozzello,Public Wo or FROM: Eric Johnson,City Admin RE: MEMO 1/28/05 from Kate' *a a MC Insurance Trust Tom, Enclosed you will find letter(s)dated July 26th and Oct 4a'(2004)that requests information related to loss- control prevention.Specifically,requesting information on the City's sewer cleaning/maintenance program. I recall that we had discussed this when you first came aboard that you need to address this letter and get the LMCIT some information. To date they have not received and information and the issue remains outstanding.Please prepare the necessary sewer cleaning program,perhaps it already exists in some esoteric form,into a more formalized approach.We can then begin its implementation and get the LMC what they need. Thanks Eric Cc: Judy Hoist i JA41-2872005 FR 1 1 0: 1 8 AM I R NUANCE SERVICES 1651 464 7596 P. 001 • Landmark Insurance Services .,.• Page 232 South Lake Street �._ e ��1�,..�� ���^i•..'W�4•:•�b+a ',;yu. 1 �«�i,j•'�.:i!+7&Wir':i:.ls,:�.o•4di�ts.. q'�._..r..:K .aA Forest Lake,MN 55025 OAKPA-I KT 01/28/2005 • Phone: 651464-3333 ,v � N 4 d7 ;3•• +'•' 11- 2644,'..S?.)4Y••vy:.••.o!��,�,+;:1•:,. .t..e CMC2SI01 �a': 'Ydr :J�'4G`' 7+1"lrnilt•aiar K'j;.•;rF.is;,"� EVLLG. '�1jEk1[ON:'• .. • CP . 07/01/2004 07/01/2005 City of Oak Park Heights Eric Johnson,City Admin. 14168 Oak Park Blvd PO Bx 2007 Oak Park Heights,MN 55082-6476 • .4.sc h,'•ic'.?:}:.!�r�'.i.B';„{;.��1•$:'.•cC/h,a:::,:���Mx�±i A,.e•s. i r;a!3i+.\.,.�1}fimr r r,' fr. .�. o:: 'r�rS 4 s�.'+.. "�i•.��n; r,1',r"+^•. .:•r.,�.' ^'���••. F'!�•Y.r,'',�.r.tir`.,""+S..•:�_�w"�jr y 1"�z';' •�� '^`'' •• . —I5h fg10.. � . . 'V, k , "dn 1�� .'• •aI �• ,`•'•:a: ,,...._•.....". .•• , -.�.• ..L.:• CS`„'h rlcul.:�,c':.L'•� . tio-'G.•?�,�.,:1+,i,..J,...�.''2w.,.. ci`i_+.,.:1+_.i.:r.... ..•�... , Please see the following corespondance from LMCIT. • • Though you responded last' fall to their property questions, evidently these rec' s were missed. Please let me know if you have any questions; you can reply direct to LMCIT, but it would help if I knew it had been done. Thank you. • -"r - • Kate Tipping • • • • • • • • . • 43(i -051`. JAN-28-2005 FRI 10; 18 AM LAXIONKEIKES 1651 464 7596 P. 002 J1;!V-27-2005 11:26 LEAGUE OF MN CITIES 6512811298 P.01 • FAX TRANSMISSTON LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 145 University Avenue West St. Paul,Minnesota 55103 Telephone(651)281-1200 League of MintiONOict CVO ' Facsimile(651)2$1-1298 Cities prom tin g ix'dAaneo To: Kate Tipping From: Pat Mingce CPCU CIC LMCIT Underwriting Fax Number: 651-464-7596 Total Pages: Including Cover • Date: January 27,2005 • Subject: City of Oak Park Heights Re; Loss Control Recommendations A letter listing a number of Loss Control recommendations Was sent to the Administrator of the City of Oak Park sleights on October 4,2004 with u copy to your office. To date, we have not had any response to the status of those recommendations. new se contact the City and advise when a response to the recommendations will be done? Let me know'Uwe can assist in any way. • Thank you for your attention to this matter. ram enclosing another copy of the recommendations for your review. • • • • • Please deliver this facsimile transmission to the above address, if Y ou slid not receive all of the pages in good condition,please advise Pat Mingce at(651)215-4081/800-925-1122 ext.4081. JAN-28-2005 FRI 10: 18 AM Lei INISfRVIIIS $651 464 7596 P. 003 JAN-27-2005 11:26 LEAGUE OF MN CITIES 6512811298 P.02 OF TA CITIES INSURANCE TRUST LEAGUE orIIVNZ;�o c Loss Control Services Administration: ciu Berkley Risk Administeators Company,LLC 222 South Ninth Street,Suite 1300,Minneapolis,Minrn OO;55402•3332 I.ao,put clMithta,alu CIIHPr Phone:(612)766-3000 Fax(612)766-3199 Citiar,oromooilnq oxeellvAa, Web Site: www.lnmc.or; NO RESPONSE October 4, 2004 bate: 21 /c'/ AZ. 6Mr. Eric Johnson LCC: Administrator City of Oak Park Heights 14168 Oak Park Blvd. Oak Park Heights,MN 550$2 • Dear Mr. Johnson: • A lector listing a number of loss control recommendations was sent to your attention on July 26,2004. A copy of that letter is attached for your reference. These loss control recommendations were a result of a r ecettt lass control survey of the premises and operations of the city in conjunction with the city's participation in the League of Minnesota Cities Insurance Trost property and casualty program. According co our records, we have not as yet received ix response to this recommendation letter. Would you please advise me of the steps you have taken to address these loss control recommendations?Feel free to write your comments directlls th •'e ,m endation letter and return it to Pie. . Return With File Thant:you for your assistance, _ Pat in Flle • Since::•ely. t Mark E. Casey, CEP, ARM, ALCM Senior Loss Control Consultant Berkley Risk Administrators Company, LLC Enclosure • • c: Forest Lake Insurance Agency, 232 South Lake Street,Forest Lake,MN 55025-2605 • r[JG ikrtt)S� I1^ f v G AN EQUAL OPPOaTuNirY/A!'ftlltMAT1Y ACTION 13MPLOY6it JAN-28-2005 FRi 10: 19 AM L I!.,,,;y. INSENCESERVI S 1651 464 7596 P. 004 JAN-27-2005 11 26 LEAGUE OF MN CITIES 6512811298 P.03 � MINNESOTA Cants Il*N$Ux4A.1Vcg TRUST Loss Control Services Administration; LM/C ' c1 Berkley Risk Administrators Company,LLC league of i,:)raaotre Ciao, 222 South 9'4 Street,Suite 1300,Minneapolis,Minnecotu 55402.3332 (ter/promoting mad/once Phone; (612)766-3172 Yam (612)766-3199 Web Site: www,ttn►tc.Q g July 26,2004 Mr. Eric Johnson City Administrator City of Oak Park Heights 14188 Oak Park Blvd Oak Park Heights, MN 66082 Deer Mr.Johnson; A routine loss control survey was recently conducted concerning certain premises and operations for the city,This was in conjunction with the City's participation in the League of Minnesota Cities Insurance Trust (t.MCIT)property, liability and workers'compensation program,The purpose of rriy visit was to assist the city In the reduction of potential foss through loss control and risk management activities. As a 'esuit of this lose control survey, l have developed the following recommendations. We have found that compliance with leas control recommendations can assist in minimizing the potential for loss, • 1/7104 Sewer cleaning should be scheduled on a continuing basis to ensure that priorities are maintained for sewer mains that have blockage problems such as tree roots, grease buildup or design problems that impede proper flow, Most cities develop a schedule that provides a complete cleaning of city ewer mains on a 3 to 5—year basis. Written records are kept on file on sewer cleaning, lift station checks and other maintenance.Video taping is also useful in establishing priorities and maintain records of cleaning and repairs. 2/7/04 8tieSOnel employees should provided format training in appropriate employment poNolee such e sexual harassment prevention to ensure that they understand them and will comply with them. The long-term benefits and successes that oan be enjoyed by a cooperative, self-Insurance organization depend upon serious and careful consideration of loss control recommendations. in that context, we ask that you keep us informed of the steps you take to address these loss control recommendations. Therefore, please respond within 60 days of your receipt of this leiter regarding the status of how you intend to respond to these loss control recommendations. I appreciate the time and courtesy extended to me at the time of my loss control visit. If I can be of any assistance before my next visit, please do not hesitate to contact me. Sincerely, Mar .-Vase CSAAa M Y � R ,At.CM • Senior Loss Control Consultant Berkley frisk Administrators Company, LLC illEnciosure:Sewer maintenance log • AN MN/ALAPPNITINI7vURH11ShA .1.1%r. __ JAN-28:2005 FRI 10: 19 AM L i lidRU!( S 1651 464 7596 P: 005 t . JAN-27-2005 11:27 LEAGUE OF MN CITIES 6512821298 P.04 Pepe 2 • CC: FOREST LAKE INSURANCE AGENCY,' DBA LANDMARK SNSU ANCE SVCS 232 S LAKE ST FOREST .LAKE MN 550252605 Recommendations and comments are provided for loss control and risk exposure improvement purposes only in conjunction with the insurance program referenced above, They are not made for the purpose of complying with the requirements of any law, rule or regulation, We do not infer or Imply in the making of those recommendation° and comments that all sites were reviewed or that all possible hazards were noted. 'Cho final responsibility for conducting loss control and risk management programa must rest with the insured. A • • • • • • • • • TOTAL P.04 • • • • C +Ai \;;;-„-t ��5t�3 O•�ti^s` " 'u v>' ' u y h g , fi r7 • '" M a Sx �fsar ; �� " � 4 ,� y s" "; 5p.� ' 4 't ;*� : �y. 4' '3 "° . +LH� `t SZ �,£ . sk ,,,,,o," ,+ re cp . 6 ; J Y Fri § v(` HS �.`. iw 4..a�'. J '" .v'-+1..' 1 W s ' City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 . Facsimile(651)439-0574 facsimile transmi ttal To: .f/n G, Fax: 6 5-s-/_ &.) ..,./ 2 From: (,L cQ. (,_l,?I, r Date: -4, Re: U.)C..- I(-7✓1-e i..i� -... ex- Pages: 3 CC: ❑Urgent ❑For Review 0 Please Comment 0 Please Reply ❑ Please Recycle Notes: • III 'Y l N+ '�r ,t e is rt 3 z a{ a4 -° z r a "�' "'.. xi 1 z r.' t 43H r fit'. ,c .w h r s , .s s. . ors { al a. �y�?aci'kt; r4i i ,F'7 v 41 a i i i c t iI'.-441,'",:%,3,4. 5 4F (i��0 i # �ua,�r r'`�"�,ti. r�t }� i p'S..i 4,c i e 7� 1 i a'iLu;'6', 0 ;,,c4 • League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 III RENEWAL DATA The "City:" OAK PARK HEIGHTS, CITY OF Agreement No. : 0200072918 PO BOX 2007 Quote To: OAK PARK HEIGHTS MN 55082 Quote Due On: 6/01/05 Agreement Expires: 7/07/05 Your coverage under the LMCIT Self-Insured Workers' Compensation program will expire soon. This Renewal Data sheet will be used to generate a premium quote for the different workers' compensation plans available. A copy of the City's previous year's selected coverages and premiums is attached for your reference. Coverage Options All of the options available to the City are outlined below, and described in the accompanying memo, Things to Think About When Renewing Your City's Workers' Compensation Coverage.You can select any coverage options in which the City may be interested. Premium quotes for all coverage options will be provided, and a final coverage decision can be made at the time you receive the complete quote. Elected Officials: Please indicate if the City would be interested in covering elected officials. Yes X No If yes, please list the estimated annual payroll for all elected officials the City would like to cover under workers' compensation. The 2002 premium rate for mayors and council members is $.37 per$100 of payroll. This rate is applied to the greater of either the official's actual salary or an imputed salary of$70 per week. Note: Coverage for elected officials requires a resolution passed by thoty Council. Payroll Description Code Amount Elected Officials 9411 $ 26,000 Members of Separate Administrative Boards:Please indicate if the City would be interested in covering members of separate administrative boards. Yes X No If yes, please select any separate administrative boards the City would like to cover under workers' compensation. (This coverage includes Board Members only.) 1. Utility or utility commission 5. Welfare or public relief agency 2. Port authority 6. School board 3. Housing and redevelopment authority 7. Joint powers board 4. Hospital or nursing home board or commission 8. X Other EDA, Parks & Planning Com!Yi.ssion (volunteers) Employees of Separate Administrative Boards:If the City has elected to cover specific Board Members above, the City can also choose to cover employees of those boards. Please indicate which type of quote the City would like: No quote for administrative board employees. Combined quote to include employees of both the administrative board and the City. Separate quote for employees of the City and each administrative board selected above. Volunteers: Please indicate if the City would be would like to cover City volunteers not designated as employees, such as c s, instructors, event workers, "clean-up" day volunteers, etc. (Volunteer firefighters, ambulance attendants, first reponders, fit forcement assistance volunteers, civil defense volunteers, and any other volunteers defined by statute as employees for purposes of work comp coverage are already covered and are not part of this election.) Yes No X (over) _A City Employees: Please indicate the estimated payroll for City employees for the coming policy year. The payroll descriptions and codes provided are the most commonly used. If you need to add additional payroll descriptions, please use the blank spaces and the c on the attached list. Sick, holiday, and vacation pay should be included in the payroll totals. Do not reduce payrolls for sick, holiday, and vacation pay. Does your City have a flexible benefits plan such as a cafeteria plan, Section 125 plan, or flexible reimbursement account plan? Yes X No Employee contributios to a flexible benefits plan should be included in the payroll figures you provide. City contributions should not be included. (This is similar to how these plans are treated under PERA.) Payroll Description Code Amount Payroll Description Code Amount Ambulance Services(Not 65,334 Volunteer) 7380 $ Sewage Plan 7580 $ _ Ambulance Services(Volunteer) 7381 $ Off Sale Liquor Store 8017 $_ r Building Operations 9015 $ Street and Road Construction 5506 $ r,422 City Shop and Yard 8227 $ Waterworks 7520 $ 1.08,889 Clerical Office 8810 $-367,466 Other: Mayor & Council 9411 $ 26,000 Electric and Steam Power 7539 $ Other: Rink Attendants 9016 $ 4,865 Firefighters(Not Volunteer) 7706 $ Other: $ Firefighters(Volunteer) 7708 pop . Other: $ Municipal Employees 9410 $ 79,101 Other: $ Parks 9102 $ 703 ,817 20,109 Other: $ Police 7720 $ 3 Other: $ Restaurant and Bars(on sale) 9084 $ Other: $ • PREMIUM OPTIONS Please select the premium options below in which the City is most interested. All of the premium options selected will be quoted to City; however, only one premium option can be ultimately assigned for the coming plan year. Regular Premium Option: Please indicate if the City would be interested in the regular premium option. Yes No X Deductible Options: Please Indicate the deductible level and associated premium discount the City would like to consider. Deductible Premium Credit $250 2.00% $500 3.50% $1,000 5.50% $2,500 9.50% $5,000 13.00% $10,000 18.00% X Retrospective Rating:Please indicate if the City would be interested in retrospective rating(if applicable). Yes No Managed Care Option: Please indicate if the City participates in a state-certified managed care organization (MCO) for workers' compensation benefits, and if so, the name of that organization. Yes No X MCO: Contact Information: Please provide us with a contact for questions about the City's workers' compensation coverage. ontact Person Judy Hoist Phone 651-439-4439 Email 3holstcityofoakpark heights.corn Please fax this completed form to the League of Minnesota Cities Insurance Trust at 651-281-1297. If you have any questions, please contact Barb Meyer, Policy Services Technician, by phone at 651-215-4173 or 800-925-1122, or via email at bmeyer2 @lmnc.org. City Employees: Please indicate the estimated payroll for City employees for the coming policy year. The payroll descriptions and codes provided are the most commonly used. If you need to add additional payroll descriptions, please use the blank spaces and the codes on the attached list. SiZ�I, oliday, and vacation pay should be included in the payroll totals. Do not reduce payrolls for sick, holiday, and vacation pay. Does your City have a flexible benefits plan such as a cafeteria plan, Section 125 plan, or flexible reimbursement account plan? Yes No Employee contributios to a flexible benefits plan should be included in the payroll figures you provide. City contributions should not be included. (This is similar to how these plans are treated under PERA.) Payroll Description Code Amount Payroll Description Code Amount Ambulance Services(Not Volunteer) 7380 $ Sewage Plan 7580 $ GS 33y Ambulance Services(Volunteer) 7381 $ Off Sale Liquor Store 8017 $ Building Operations 9015 $ Street and Road Construction 5506 $ (7 y". City Shop and Yard 8227 $ Waterworks 7520 $ /p$' gc?, Clerical Office 8810 $ 31.2 ,-/C4 Other: 911f-rrlo tc'v...F<. F` qyt I $ 2 4.4.0o Electric and Steam Power 7539 $ Other: p_,,,',,,,(� &,416-....�(c,,4 .' of L$ /, $'(i5 Firefighters(Not Volunteer) 7706 $ Other: $ Firefighters(Volunteer) 7708 pop Other: $ Municipal Employees 9410 $ 7 9 /Of Other: $ Parks 9102 $ PQ,f s3 1 Other: $ Police 7720 $ 7o-,� g`y 7 Other: $ Restaurant and Bars(on sale) 9084 $ Other: $ 1 3 ci a O!o 3 PREMIUM OPTIONS Pe select the premium options below in which the City is most interested. All of the premium options selected will be quoted tc City; however, only one premium option can be ultimately assigned for the coming plan year. Regular Premium Option: Please indicate if the City would be interested in the regular premium option. Yes No Deductible Options: Please Indicate the deductible level and associated premium discount the City would like to consider. Deductible Premium Credit $250 2.00% $500 3.50% $1,000 5.50% $2,500 9.50% $5,000 13.00% $10,000 18.00% Retrospective Rating:Please indicate if the City would be interested in retrospective rating(if applicable). Yes No Managed Care Option: Please indicate if the City participates in a state-certified managed care organization (MCO) for workers' compensation benefits, and if so, the name of that organization. Yes No MCO: Contact Information: Please provide us with a contact for questions about the City's workers' compensation coverage. C' Contact Person Phone Email Please fax this completed form to the League of Minnesota Cities Insurance Trust at 651-281-1297. If you have any questions, please contact Barb Meyer, Policy Services Technician, by phone at 651-215-4173 or 800-925-1122, or via email at bmeyer2 @lmnc.org. Comp Time Prey. Yr 05' 06' Holiday Overtime 05'+06' earings Council David Beaudet 3,000 3,000 $ 6,000 $ 6,000 Les Abrahamson 2,500 2,500 $ 5,000 $ 5,000 Jack Doer 2,500 2,500 $ 5,000 $ 5,000 NEN McComber 2,500 2,500 $ 5,000 $ 5,000 INK Swenson 2,500 2,500 $ 5,000 $ 5,000 Total $ 26,000 $ 26,000 9411 Part Time Parks John Sortedahl 2,160 2,461 $ 4,621 Brandon 1,131 $ 1,131 Brianna 1,048 $ 1,048 Ryan 1,009 $ 1,009 Amy Engleman 1,921 $ 1,921 Total $ 9,730 9102 $ 4,865 9016 $ 4,865 Police Stanley Buckley 31,364 32,305 2,994 1,388 $ 68,051 $ 65,152 1.04 Michael Hausken 35,559 36,626 3,771 655 $ 76,611 $ 73,340 1.04 Lindy Swanson 42,834 44,119 1,648 $ 88,601 $ 84,772 1.05 Kenneth Anderson 32,328 33,298 3,260 149 $ 69,035 $ 66,079 1.04 Paul Hoppe 35,559 36,626 3,520 983 $ 76,688 $ 73,415 1.04 Fred Kropidlowski 31,364 32,305 3,105 3,166 $ 69,940 $ 66,985 1.04 Brian DeRosier 31,723 32,675 3,260 97 $ 67,755 $ 63,686 1.06 Joseph Croft 31,076 32,008 2,439 6,838 $ 72,362 $ 69,350 1.04 David Kisch 31,076 32,008 3,326 290 $ 66,701 $ 63,854 1.04 Sandra Kruse-Roslin 23,603 24,311 221 $ 48,135 $ 46,049 1.05 TAiii $703,877 7720 111/0ffi Staff Gary Brunckhorst 27,429 28,252 - $ 55,681 $ 51,262 1.09 Judy Hoist 40,533 41,749 1,559 $ 83,841 $ 79,650 1.05 Julie Hultman 25,938 26,716 998 $ 53,652 $ 46,930 1.14 Eric Johnson 40,188 41,394 - $ 81,582 $ 77,943 1.05 Julie Johnson 21,870 22,526 841 $ 45,237 $ 43,287 1.05 Lisa Taube 23,386 24,088 - $ 47,474 $ 45,169 1.05 Total $367,466 8810 Building Insp. Jimmy Butler 33,602 34,610 $ 68,212 $ 65,252 1.05 9410 Breakdown Public Works Jeff Kellogg 27,429 28,252 6,932 $ 62,613 $ 58,708 1.07 5506 17,422 Andrew Kegley 15,156 17,844 1,910 $ 34,910 $ 77,692 0.45 7520 108,889 Tom Ozzello 36,222 37,309 1,396 $ 74,927 $ 24,054 7580 65,334 Mark Robertson 18,880 21,876 4,573 $ 45,329 $ 23,395 7720 703,877 8810 367,466 Total $217,779 9102 20,109 Public Works Breakdown 9410 79,101 9102 8% $ 217,779. 15,244 Parks .'" 9411 26,000 5506 50% 17,422 Streets 9016 4,865 108,889, ,. 7520 30% 108 Wat et'...:! 7580 7% 66,334 °Sewer 1,393,064 • 9410 5% 10,889 Storm Sewer $ 1,393,064 9,730 Parks Workers League of Minnesota Cities Insurance Trust 145 University Avenue West,St Paul,MN 55103-2044 (651}2811200 •L ;GinQroEa C�EiQS Fax:(651)281-1298 • TDD:(651)281-1290 g a' noa wwwamnc.or g MINNESOTA WORKERS' COMPENSATION . NOTICE OF RENEWAL This information is provided to assist you in understanding your workers' compensation coverage and renewal options. Please read all the information carefully before making selections for the next coverage period. The following information is included: • Renewal Data Form • Copy of previous year's coverage selection and premium information page • Risk management memorandum: Things to Think About When Renewing Your City's Workers' Compensation Coverage If you have additional questions about the coverage options available to your City,please contact the League of Minnesota Cities Insurance Trust: 411 Barb Meyer, Policy Services.Technician Jan Kodet,Underwriting Supervisor Phone: 651-215-4173 Phone: 651-215-4082 Fax: 651-281-1297 Fax: 651-281-1298 Email: bmeyer2@lmnc.org Email: ikodet@lmnc.org Deb Anger, Claims Manager Bill Everett, Associate Administrator Phone: 651-215-4170 Phone: 651-281-1216 Fax: 651-281-1297 Fax: 651-281-1298 Email: danger(a lmnc.org Email: beverett@lmnc.org Any of the above listed individuals can also be reached at 800-925-1122 • AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 Phone (651)215-4173 • Information Page 1. The "City" RENEWAL Agreement No.: 0200072918 OAK PARK HEIGHTS, CITY OF PO BOX 2007 "City" is: x City OAK PARK HEIGHTS MN 55082 _ Joint Powers Entity C;'1 P 1 i i I i` G i '9 �,� €'y' ' `!u N _ Other (describe) DO �` 2. The Agreement Period is from 12:01 a.m. 7/07/2004 to 12.01 a.m. 7/07/2005 at the "City's" address. 3. A. Workers' Compensation Coverage: Part One of the Agreement applies to the Workers' Compensation Law of any state of the United States of America and the District of Columbia. B. Employers Liability Coverage: Part Two of the Agreement applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury-Each Occurrence $1,000,000 Bodily Injury by Disease-Agreement Limit $1,000,000 C. Part Three of the Agreement applies to Infectious Disease Diagnostic Testing. D. Part Four of the Agreement applies to Peace Officers' Posttraumatic Stress Syndrome Benefit. E. This Agreement includes these amendments and schedules: S 4. Retro-rating option selected? Yes x No 5. Elected Officials Covered? Yes Boards and Commissions Covered (List) NONE 6. The premium for this Agreement will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rates Entries in this item,except as specifically provided Estimated Estimated Total Per$100 of Code elsewhere in this Agreement; Do not modify any of the Annual Annual Remuneration No. other provisions of the Agreement Premium Remuneration SEE ATTACHED SCHEDULE FOR DETAILS FXP1T N IN O " 7 Manual Premium 32886. §�} D4 N - f;",,'=' Experience Modification .83 5591. NOT Premium 27295. Managed Care Credit 0% Deductible Credit .0 % Agent: 411709883 503.54 Premium Discount 2118. 11874 FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS Net Deposit Premium 25177. 232 S LAKE ST FOREST LAKE MN 55025- 7/23/2004 LM 4670(12/99) League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 (651)215-4173 Ole"City" Agreement No.: 0200072918 Agreement Period From: 7/07/2004 OAK PARK HEIGHTS, CITY OF To: 7/07/2005 PO BOX 2007 OAK PARK HEIGHTS MN 55082 CONTINUATION SCHEDULE FOR INFORMATION PAGE REMUNERATION RATE CODE DESCRIPTION EST. PREM 13870. 6.27 5506 STREET CONSTRUCTION 870. 86689. 2.70 7520 WATERWORKS 2341. 52014. 3.59 7580 SEWAGE DISPOSAL PLANT 1867. 678375. 3.61 7720 POLICE 24489. 349018. .54 8810 CLERICAL OFFICE EMPLOYEES NOC 1885. 11372. 2.26 9016 SKATING RINK OPERATION 257. 12136. 2.86 9102 PARKS 347. 74900. .98 9410 MUNICIPAL EMPLOYEES 734. 26000. .37 9411 ELECTED OR APPOINTED OFFICIALS 96. Manual Premium 32886. S Y1'Yk∎I ii- V ` ' i!r 11®1Y 0-t' fl6V Agent: 411709883 00874 : FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST FOREST LAKE MN 55025- 7/23/2004 LM 4680(8/99) • LMC 145 University Avenue West, St. Paul, MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 TDD (651) 281-1290 League of Minnesota Cities LMC Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities promoting excellence yy Wei) Site: http://www.lmne.org March 2002 To: LMCIT Workers' Compensation member cities Re: Certification of non-smoking status for police and fire department members The League of Minnesota Cities Insurance Trust(LMCIT)allows cities a 10 percent reduction in the premium charged for workers' compensation coverage for police and fire departments,if the city can certify that at least 90 percent of the department's members are non-smokers. To certify non-smoking status,cities must ask police and fire department staff to fill out a form indicating that they do not smoke. This information is private employee data. LMCIT recommends that police and fire department members be provided with appropriate information about the request when it is made of them(Tennessen warning). It is the city's responsibility to provide appropriate information about why this private data is being requested from the employee,and also to maintain the information correctly. To help you with this process,LMCIT is providing a sample non-smoking certification that includes a Tennessen warning to the employee. This sample document is on the back of this page,and can be copied for city use. LMCIT will also accept other certification that the city might choose to submit from police or fire department staff. Please keep in mind the need to provide employees with information about why the request is being made,what the data will be used for,and who will have access to the data submitted. If you have any questions,please contact LMCIT at 651-281-1200 or 800-925-1122. • AN EQUAL OPPORTUNITY/ANriRMATIVE ACTION EMPLOYER / Notice to Police and Fire Department Members gi City of Fire Department or Police Department The League of Minnesota Cities Insurance Trust(LMCIT)allows cities a 10 percent reduction in workers' compensation premium for police and fire departments,if the city can certify that at least 90 percent of department members are non-smokers. The information below is requested in order for your city to receive this discount. The information will be submitted by the city to LMCIT,where it will be used to determine premium discount status.You are not required to provide this information at this time. If you refuse to supply the information,you will face no disciplinary action as a result of the refusal. However, • If you provide false or misleading information,it may be used by the city to impose discipline against you,including dismissal;and • At some point in the future,the city may choose to require you to provide this information. At that time,you will be provided another advisory telling you of the requirement and the consequences for refusing. Other persons or entities who are authorized by law to receive this information are: employees,agents,and officials of the city who have need to know about the information in the course of their duties or 0 responsibilities,the person who is the subject of the data about him or herself,people who have permission from the subject of the data,and LMCIT. If it is reasonably necessary to discuss the information at a city council or board meeting,it will be available to members of the public. Advisory provided to by (employee) (city contact) on at (date) (time) EMPLOYEE COMPLETES THIS PORTION: I acknowledge receiving this advisory. I do not smoke and have not smoked within the past six months. (signature) (date) ill LMCIT LMC Risk Management Information • League of Minnesota Cities 145 University Avenue West,St.Paul,MN 55103-2044 Cities promoting excellence Phone: (651)281-1200• (800)925-1122 Fax: (651)281-1298 • TDD(651)281-1290 www.lmcit.lmnc.org THINGS TO THINK ABOUT WHEN RENEWING YOUR CITY'S WORKERS' COMPENSATION COVERAGE The LMCIT workers' compensation program is specially designed for Minnesota cities. LMCIT's coverage is unique because it picks up some related risks that standard workers' compensation insurance policies don't cover. This program also offers a number of coverage and premium options, deductibles and credits. LMCIT tries to make buying coverage for the city's workers' compensation exposures as simple and straightforward as possible, but there are still a number of decisions the city needs to make in renewing its work comp coverage. This memo is intended to serve as a guide for cities and agents when thinking about purchasing or renewing work comp coverage. BOARDS AND COMMISSIONS • Elected officials Unlike city employees, elected officials are not automatically covered by the work comp law. Cities wishing to cover elected officials need to pass an ordinance or resolution to make the elected officials "employees" for purposes of work comp coverage. If the city does not pass the resolution, a city official that is injured while on city business wouldn't receive any work comp benefits from the city. This mostly affects mayors and council members, but it could also apply to clerk,treasurers, and other officers in cities where those are elected positions. The 2005 premium rate for mayors and council members is $.39 per$100 of payroll. This rate is applied to the greater of either the official's actual salary or an imputed salary of$70 per week. In case of injury, an elected official would receive the same work comp benefits as any other city employee. Indemnity benefits would be based on the sum of his/her earnings from his/her regular employment plus the actual salary (if any) s/he receives from the city. An alternative to work comp coverage for elected officials is to purchase LMCIT's board member accident coverage. Under this option, cities can provide more limited benefits to council members injured or killed in the course of performing their duties. Accident policy rates for 2001 are $12.75 per person per year. Benefits are paid for death or short-term disability. This program was originally developed a number of years ago as a low-cost alternative to work comp for elected officials. However, LMCIT has reduced the cost of work comp for elected officials very substantially since then, so the cost advantage of the accident coverage option is now minimal. Here's a summary comparison of the two ways cities can cover elected officials through LMCIT: LMCIT elected officials work LMCIT elected officials accident comp coverage coverage Premium cost $.37 per$100 of actual payroll or $12.75 per person per year imputed salary Coverage benefits • Death • Death • Short-term disability • Short-term disability • Loss of wages • Rehabilitation • Medical expenses • Permanent disability For more information about coverage for elected officials, refer to the "Coverage for Injuries to Elected and Appointed Officials"memo, fax number 66040. Members of separate administrative boards • Members of administrative boards that the city creates pursuant to statute or charter can also be covered by workers compensation in the same way as elected officials if the city passes the appropriate ordinance or resolution. Common examples of these types of boards include planning commissions, housing and redevelopment authorities,port authority boards,EDA boards, utilities commissions, park boards, and hospital or nursing home boards. The accident coverage alternative is also available for these positions. For more information about coverage for members of separate boards, refer to the "Coordinating Coverages for Separate City Boards and Commissions"memo, fax number 66260. Employees of separate administrative boards In some cases, the city may prefer that entities which are managed by a separate administrative board have their own work comp coverage separate from the city. HRAs, EDAs,port authorities, utilities commissions, and hospital or nursing home boards are examples. Alternately, these employees can be included under the city's general coverage. Having separate coverage may make it easier to allocate costs appropriately between the two budgets. Another reason cities sometimes choose to use separate coverage is so each operation stands on its own for purposes of the experience modification calculation. I.e., with separate coverage, the utilities commission's employees losses won't affect the city's experience modification, and vice versa. On the other hand, by separating the two,the city may lose some • benefit of the volume discount on premiums. 2 LMCIT can provide the coverage either way, but the important thing is to make sure that all • parties involved are clear on what the intent is. Note that employees of an utilities commission, HRA, EDA, port authority, or hospital or nursing home board are not automatically covered by the city's LMCIT work comp coverage unless that board is specifically listed on the information page of the coverage document. Joint powers boards If a joint powers board has its own employees, it needs work comp coverage. Any joint powers board which has at least one city as a member is eligible for LMCIT work comp coverage. LMCIT can provide that coverage either by issuing separate coverage to the joint powers board, or by adding the joint powers board as a covered employer on the city's LMCIT work comp coverage. Advisory boards Unpaid members of advisory boards that do not have legal decision-making authority are not eligible to be covered by work comp. However, cities may obtain board accident coverage from LMCIT for members of advisory boards at the same rate as for administrative boards. VOLUNTEERS Volunteers considered employees 110 Certain volunteers are defined by statute as employees for purposes of work comp coverage. These include volunteer firefighters, ambulance attendants, first responders, law enforcement assistance volunteers, and civil defense volunteers. These volunteers are entitled to receive work comp benefits if they are injured while performing volunteer services for the city, and are covered under the city's regular work comp policy. Volunteers in an Emergency City volunteers at work during an emergency are entitled by statute to work comp benefits under a city's policy. Emergency city volunteers must be registered with the city and work under the direction and control of the city. LMCIT does not charge any additional premium for this work comp exposure. (Like other city volunteers, emergency volunteers are also automatically "covered parties" under the city's LMCIT liability coverage.) For more information, refer to the "Providing Assistance in Emergencies: Coverage and Liability Issues"memo, fax number 66840. Other city volunteers Other city volunteers are not considered employees and are therefor not covered by workers' compensation. For these volunteers, LMCIT offers an optional volunteer accident coverage, which provides some limited"no-fault"benefits for volunteers injured while working for the city. Volunteers under this program receive limited death, disability and impairment benefits. 3 The city can also add coverage for up to $1,000 of medical costs for an additional charge. This • coverage could help avoid litigation in cases where the city may be at fault, and it also provides some protection for people donating their time and effort to city projects. Volunteer accident coverage provides blanket coverage for all city volunteers working under city direction and control, such as coaches and instructors in recreation programs, or volunteers working on city-sponsored festivals or celebrations. The cost of volunteer work comp coverage is based on the city's population,with a basic annual charge of$.10 per capita subject to a minimum premium of$150 and a maximum premium of$1,500 annually. The charge to add volunteers working on a construction project is $300 per project. For more information,refer to the "Accident Coverage for City Volunteers" memo, fax number 66050; and the"Covering the City's Volunteers"memo, fax number 66030. PREMIUM OPTIONS LMCIT work comp members have a number of premium options as well as an option to close- out retro coverage from previous years. Members also have the option of using a managed care provider for the medical management of employees injured while at work. Regular Premium Under the regular premium option, the City's premium is calculated based on City payroll, by S class. The premium is then adjusted by an experience modification factor, which reflects the City's previous loss experience. In the experience modification process, claims in the oldest three out of the past four years are considered. In other words,the most recent past year is not considered. If a city chooses the regular premium option,premium payments are the City's only responsibility or liability. The regular premium option is a"fully insured" option for the City to elect. Retrospective rating Under LMCIT's retro-rating plan, a city's final premium costs reflects its own, actual loss experience for the year. Cities with standard premiums of$25,000 or more are given the choice of three retrospective options, so that each city may select the amount of risk it wishes to retain. Retrospective rating gives cities the closest option to self-insurance. Since the final premium will be a function of the city's own losses, a good safety and loss control program can save the city money over the long run. On the other hand, the city would also be subject to premium increases if it experiences a big loss. Cities that select a retrospective rating option pay a deposit premium to LMCIT at the beginning of the agreement period. Six months after the end of the agreement year, the city's premiums are • 4 adjusted up or down based on the city's actual incurred losses for that year. That adjustment is • repeated annually until all claims from the agreement period are closed. Before selecting retro rating, a city may wish to do a"what if' calculation of what the city's premiums would have been for each of the past few years if the city had had a retrospective rating plan in place. This can be a useful tool for cities evaluating retrospective rating options. For more information about the retrospective rating options, refer to the "Workers' Compensation Retrospective Rating Options" memo, fax number 66360. Retro close-out option After five years participation in a retro program, cities have the option to close out retro-rated coverage from previous years. If a city closes out the retro, no further adjustments are then made to the city's premiums under the retro-rated formula, regardless of what future changes there may be in the city's paid or incurred losses. The charge for the close-out is a percentage of the city's incurred losses for the coverage year in question. You may call Barb Meyer at 651-215- 4173 to calculate your city's close-out charges. For more information about the retro close-out option, refer to the "Workers' Compensation Retro Close-Out Option"memo, fax number 66320. Deductible options • Under a deductible option,the city pays lower premium in return for agreeing to reimburse LMCIT for paid medical losses up to a set deductible. If the city selects a deductible option, the deductible applies per occurrence to medical costs only. There are six deductible options ranging from a$250 deductible with a 3.0 percent premium credit to a$10,000 deductible with an 20.0 percent premium credit. Deductibles do not affect the experience modification calculation. Even though under a deductible option the city reimburses LMCIT for certain medical costs, those costs are still included in calculating the experience modification. For more information on deductible options, refer to the "Workers' Compensation Deductible Options"memo, fax number 66350. Managed care option Cities that enroll with a state-certified managed care organization(MCO)receive a 3%premium credit on their work comp coverage. MCOs attempt to reduce the total costs of work comp claims by providing care in a network setting, establishing cost effective treatment protocols, and working to return the employee to work as soon as possible. If the MCO is successful in reducing loss costs, the city would see additional savings in the form of an improved experience modification. • 5 LMCIT has been monitoring cities' experience with MCOs for several years. The results are not • clearcut,though the most recent review suggests that managed care may be producing at least some overall savings for some cities. There are a number of certified MCOs in Minnesota, but the two that cities have most often used to date are CMC (a Blue Cross subsidiary) and Corvel. Some factors to look at in selecting an MCO are whether the MCO has network providers in their area; the MCO's fees and charges; and whether the MCO's overall approach and philosophy matches the city's. For a list of certified MCOs, contact the Department of Labor and Industry at 800-342-5354 or www.doli.state.mn.us. Non-smoker credit for police and firefighters LMCIT offers member cities a 10 percent rate credit for non-smoking police and firefighters. To qualify for the credit, the city must obtain written statements of non-smoking from at least 90 percent of the members of the department. The statement must be signed and dated, and must state that the individual does not smoke and has not smoked within the previous six months. LMCIT gives this discount because several of the diseases presumed by statute to be job-related for firefighters and police officers—various heart diseases, lung diseases, and cancers—are also related to smoking. Fire or police departments with very few smokers represent a lower risk for claims for heart disease, lung disease, or cancer. • For more information on how this credit works,refer to the"Workers' Compensation for Volunteer Firefighters" memo, fax number 66020. AG 9/01 S 6 07/21/2004 WED 11:27 FAX @6001/001 ACORD. INSURANCE BINDER OP ID KT DATE 07/21/04 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT,SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. PRODUCER u�alc°NaE>R): 651-464-3333 COMPANY BINDERLI 1057 651-464-7596 LMCIT-BerkleRisk Services, I ERPifWTION dmark Insurance Services GATE - TIME DATE TIME ' 232 South Lake Street X AM X 1x01 AM Forest Lake ITT 55025 _0_7/07/04 12:01 PM 07/07/05 NOON Landmark Insurance Services THIS BINUEH 15 ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY CODE: 'SUB CODE: X PER EXPIRING POLICY"' ALL LMCIT POL'S CU II: OAKPA-1 DESCRIPTION OF OPERATIONS NEHICLESIPROPERTY(IACludIn0 Location) INSURED City of Oak Park Heights Eric Johnson, City Admin. 14168 Oak Park Blvd PO Bx 2007 Oak Park Heights MN 55082-6476 t _ COVERAGES LIMITS TYPE OF INSURANCE COVERAGEJFORMS DEDUCTIBLE COINS% AMOUNT PROPERTY CAUSES OF LOSS Special; Replacement Cost 500 90 5,732,462 BASIC ` BROAD X SPEC GENERAL LIABILITY EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) S 5 0,000 'CLAIMS MADE OCCUR MED EXP(My one person) $ 1000 X OPEN MEETING LAW PERSONALS ADV INJURY $1,000_,000 �� GENERAL AGGREGATE 51,000,000 RETRO DATE FOR CLAIMS MADE: PRODUCTS-COMPIOP AGG 51,000,000 AUTOMOBILE UABILITY COMBINED SINGLE LIMIT 51,000,000 X ANY AUTO BODILY INJURY(Per parson) $ - CL OWNED AUTOS BODILY INJURY(Par accident) $ I ICDUCD L AUTOS PROPERTY DAMAGE _ $ X HIRED AUTOS MtOICAL PAYMENTS S X NON-OWNED AUTOS PERSONAL INJURY PROT $BASIC UNINSURED MOTORIST $1,000,000 AUTO PHYSICAL DAMAGE DEDUCTIBLE -- ALL VEHICLES SCHEDULED VEHICLES X ACTUAL CASH VALUE L X COLLISION: S 0 0 STATED AMOUNT S X OTHERTHANCOL: _ _.500 OTHER GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ^_•_ ANY AUTO OTHER THAN AUTO ONLY; EACH ACCIDCNT $ ACCRECATE $ EXCESS LIABILITY EACH OCCURRENCE $1 000,000 X UMBRELLA FORM _AGGREGATE $ 4 OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE; 07/07/87 SELF•)NSURED RETENTION S WC STATUTORY LIMITS WORKERS COMPENSATION EL EACH ACCIDENT $1_,000,000 AND EMPLOYER'S UABIUTY E,L.DISEASE-EA EMPLOYEE $1,000,00 0 E.L.DISEASE-POLICY LIMIT 31,000,000 SPECIAL CRIME - Employee Dishonesty/Faithful Performance - $100,000. limit FEES $ CONDITIONS/ COVEER TAXES S AGES ESTIMATED TOTAL PREMIUM _$ NAME&ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE .. • LOAN# AUTHORIZED REPRESENTATIVE 0AE::sese4444.44, 4e. 0‘4,010 ACORD 75-S(1198) NOTE:IMPORTANT STATE INFORMATION ON REVERSE SIDE �D CORPORATION 1993 3i-CS 1 Judy Hoist • From: Judy Hoist Sent: Monday, October 25, 2004 11:53 AM To: Kate Tipping (E-mail) Subject: OPH Property Received your fax regarding the generator and vacant property. The generator is used as a back-up power source. We do not sell electric power to other interests. It is City use only. Yes we have vacant property. The Bell property on Stagecoach Trail is vacant. The City parks are vacant in the sense there are no residential buildings on the property. Most of the parks have only small buildings for shelter and rest rooms. Autumn Hills park has no building, Swager park has no building. We also have right of ways for the roads and property where the trails are located. I'm in the process of compiling a list of City Property. Some is already on our fixed assets listing and has been for years. Let me know if you need anything else. Judy • • From:Kate Tiooina At:Landmark Insurance Services FaxID:651-464-7596 To:Judy Date:10/25/2004 11:12 AM Paae: 1 of 2 Phone: (651) 464-3333 ext. 209 Fax: (651) 464-7596 i Fax From: Kate Tipping To: Judy Pages: 2 Fax: (651) 439-0574 Date: 10/25/2004 11:12:02 AM Phone: (651) 439-4439 Subject: OPH prop memo Message: S S From:Kate Tipping At:Landmark Insurance Services FaxID:651-464-7596 To:Judy Date: 10/25/2004 11:12 AM Page:2 of 2 MEMO Page 1 Landmark Insurance Services 0,7A „,„ • 232 South Lake Street OAKPA 1 KT j aw,tF. , s s•'„� 10/25/2004 Forest Lake,MN 55025 �)'� h,''5� } 4s ^ Phone: 651-464-3333 Fax: 651-464-7596 CMC25101 Wag {fy1% i Ash” YMfir A MIS"` M7 'Il3'3A CP 07/01/2004 07/01/2005 City of Oak Park Heights Eric Johnson,City Admin. 14168 Oak Park Blvd PO Bx 2007 Oak Park Heights,MN 55082-6476 T1I 1r0$ d y f a �• w Aid* k The League would like to know if the Diesel/Electrical generator listed on the renewal application is used as a back-up power source? They also asked if you sell electirc power to other interests or if it is for city use only, I believe it ' s city use only, but please verify. They also need to know if you own any vacant property or if any of the property you own is of historic value. *Thank you. Kate Tipping i From:Kate Tipping At:Landmark Insurance Services FaxID:651-464-7596 To:Judy Date:5272004 12:37 PM Page:2 of 3 MEMO Pagel Landmark Insurance Services itomationommtwommareateisreizaraiganwalia • 232 South Lake Street OAKPA-1 KT 05/27/2004 Forest Lake,MN 55025 �f pp "�' 1€i H roF�X ate naRa} ! y A �. "gym +( Phone: 6.51-464-3333 Fax 651-464-7596 aF' �s ' �` r$ =�"#•4 �' ,, e"'f �p1-� r CAIC24118 CP 07/07/2003 07/01/2004 City of Oak Park Heights Eric Johnson,City Admin. 14168 Oak Park Blvd PO Bx 2007 • Oak Park Heights,MN 55082-6476 ii p ,.`.>{ d le * �� �� "r a 4 � �A "�Z � � � � NP � r , .17) . � 7 � � �� Amossmigi My email is balm @landmark-ins .com. Thanks ! Kate Tipping • • 1 Judy Hoist • From: MAILER-DAEMON @mailproc.sbbsnet.net Sent: Thursday, July 15, 2004 10:45 AM To: Judy Hoist Subject: failure notice Hi. This is the qmail-send program at mailproc.sbbsnet.net. I'm afraid I wasn't able to deliver your message to the following addresses. This is a permanent error; I've given up. Sorry it didn't work out. <ktippinq(a,LANDMARKINS.com>: 64.113.34.63 does not like recipient. Remote host said: 550 No such user(ktipping) -ERR ktippinq(a?landmarkins.com not found Giving up on 64.113.34.63. --- Below this line is a copy of the message. Return-Path: <jholstAcityofoakparkheights.com> Received: (qmail 26008 invoked by uid 508); 15 Jul 2004 15:45:21 -0000 Received: from jholst(a,cityofoakparkheights.com by mailproc by uid 501 with qmail-scanner- 1.21 (csav: version 4.90.1/SIGN.DEF created on Jul 14 2004/SIGN2.DEF created on Jul 14 2004/MACRO.DEF created on Jul 12 2004/spamassassin: 2.55. Clear:RC:0(66.41.83.120):SA:0(0.0/4.4):. Processed in 1.706669 secs); 15 Jul 2004 15:45:21 -0000 Received: from c-66-41-83-120.mn.client2.attbi.com (HELO w2ksbserver.oph.local) (66.41.83.120) by mailproc.sbbsnet.net with SMTP; 15 Jul 2004 15:45:19-0000 content-class: urn:content-classes:message MIME-Version: 1.0 • Content-Type: text/plain; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable X-MimeOLE: Produced By Microsoft Exchange V6.0.6249.0 Subject: RE: fax from League re: oak park heights Date: Thu, 15 Jul 2004 10:44:54-0500 Message-ID: <F6680BB850C7B343BF299C4A3694B16C1 E58E4Ca�w2ksbserver.oph.local>X- MS-Has-Attach: X-MS-TN EF-Correlator: Thread-Topic: fax from League re: oak park heights Thread-Index: AcRgcj3d+rtFH88EQPasO12giaNeAQADkTOgAACC/iA= From: "Judy Hoist"<jhoistCa.citvofoakparkheights.com> To: "Kate Tipping" <ktippingta' LANDMARKINS.com> X-Spam-Status: No, hits=0.0 required=4.4 tests=none version=2.55 X-Spam-Level: X-Spam-Checker-Version: SpamAssassin 2.55 (1.174.2.19-2003-05-19-exp) All that was in the attachment was the fax transmittal. What building = is she referring to? I thought we had everything covered. Judy Original Message • I From: Kate Tipping rmailto:ktippingca LANDMARKINS.coml Sent: Thursday, July 15, 2004 10:30 AM • To: Judy Hoist Subject: FW: fax from League re: oak park heights « File: 1522597887.tif>> Original Message From: Ann Nowezki Sent: Thursday, July 15, 2004 8:48 AM To: Kate Tipping Subject: fax from League re: oak park heights • • , JUL-15-2004 07 26 LEAGUE OF MN CITIES 6512811298 P.01 FAX TRANSMISSION League of Minnesota Cities Insurance Trust 145 University Avenue West,St Paul,MN 55103.2044 C (651)281-1200 • (800)925-1122 Caw Fax;(651)281-1298•TDD:(651)281-1290 www.lmmorg To: Irate Tipping From: Tracy Nesburg-Appraisal Coordinator Landmark Insurance Services LMCIT Underwriting tnesburg @Imnc_org Fax Number: 651464-7596 Phone Number:651-281-1212 or 800-925-1122 ext 1212 Date: 5/17/04 ovrA 7-15-04 Total Pages: 4 Subject: Oak Park Heights •Comments: We are still in need of the attached appraisal information. It is extremely important that this information is returned to ensure that each building has adequate coverage. • If the city feels their buildings have adequate coverage and an appraisal is not needed,please reply to this fax with that response. If the city wants the building appraised,please return the attached information request forms as soon as possible. Please deliver this fax to the above addressee. If you did not receive all of the pages in good condition, please advise the sender at your earliest convenience. AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER JUL-15-2004 07:27 LEAGUE OF MN CITIES 6512811298 P.02 September 5, 2003 F4ZED Landmark Insurance Services 6/----C" "c5 Agency Contact: Kate Tipping efo Phone: 651-464-3333 %)(eci Fax: 651-464-7596 // _03 City Contact: Judy or Eric Johnson,City Administrator Phone: 651-439-4439 Re: Oak Park Heights Dear Kate, LMCIT provides appraisals as a standard service to LMCIT members-The actual appraisals are performed by Maximus,a professional appraisal firm that LMCIT is using on their behalf. Maximus will perform on-site appraisals on locations with replacement cost values of$500,000 or greater and desktop appraisals on locations with replacement cost values less than$500,000.Mobile property with a replacement cost value greater than$25,000 will have a desktop appraisal.Property in the open will not be appraised. • This service should eliminate the need for further professional appraisals of the city's buildings,contents and mobile property.However,we recommend that the city review their values at each location to make sure that they appear to be reasonable. Please contact LMCIT if you need assistance. The recent change in the property coverage does place a limit on the amount of coverage available at each location. This limit is 150%of the estimated replacement cost figure as shown on the Schedule of Covered Property.The new coverage applies to each city at their first renewal on or after. November 15, 2002. During year 2003,LMCIT will automatically perform the following appraisals: • Initial appraisal on the city's property, if not already completed. • Additional appraisal on locations that the city purchased or newly acquired since their initial LMCIT appraisal. • Additional appraisal on mobile property with a replacement cost value greater than$25,000 that the city purchased or newly acquired since their initial LMCIT appraisal. • Additional appraisal on those locations with a replacement cost value greater than $5,000,000 that were newly acquired or purchased during the current year. 411 JUL-15-2004 07:27 LEAGUE OF MN CITIES 6512811298 P.03 • lithe city requests, LMCIT will perform additional appraisals on the following: • Locations with historical values. • Locations with unique architectural features. • Locations that have had major building renovations since the initial appraisal. Below is the current status of the city's appraisal and what needs to be done to complete the appraisal process. The goal is to complete this appraisal process during the year 2003. If you have any questions,please contact Tracy Nesburg,Appraisal Coordinator at 651- ' 281- 1212 or Mike Wozniak, Underwriting Manager, at 651-215-4090. Fax Number— 651-281-1298. We would like to develop this information within 45 days. • Initial appraisal was completed on the locations or mobile property as per the schedules submitted. • The covenant was endorsed and a copy of the appraisal in a spreadsheet format was sent to the agent and city. • We need to perform appraisals on those locations or mobile property that were not part of the original schedules. • In order to perform the appraisals,information is needed on the locations or mobile property indicated on the attached forms. • Please obtain and send us this information. • After we receive this information,an appraisal will be performed and the covenant will be endorsed. A copy of the additional appraisal in a spreadsheet format will be sent to the agent and city. • • This will complete the appraisal process. 170'd ibial • Hi : ' 1. 1 , : 1 •; : ' : : . , ; ; ; ; I . ; ,. ! 1 ; i; ',. ., ! ; . 1 ii. iIii ! ! • ; . ; :. :. 11 .ii ', , • . 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Judy.Hoist • From: Jay Johnson Sent: Thursday, May 20, 2004 10:56 AM To: Judy Hoist Subject: RE: Krueger Lift Station Original Message From: Judy Hoist Sent: Wednesday,May 19,2004 3:23 PM To: Jay Johnson Subject: Krueger Lift Station Jay, I will need some info from you for the appraisal for the Kern Center Lift Station for insurance purposes. 1. #of pumps 2 2. Horse Power of pumps The Pumps are Flygt CP-3140-481 480V/3PH 15 horsepower, two speed motor, with 20FLA subrmersible sewage pump and 3. GPM (gallons per minute) currently set for low speed 200 gpm at 35 feet TDH( 1150 RPM high speed is 400gpm @67feet TDH @ 1750 RPM 4. TDH (height water is lifted) TDH is not the height the water is lifted. it is the height the water is lifted plus the friction losses in the piping system. of course the insurance company does not know the difference. • At 200 gpm the TDH is 35 feet current setting (If we ever have to set it to high speed we will have 400 gpm @ 67 feet TDH) 1. Is it a submersible pump? Yes they are. 2. If not submersible pump-what is the height and diameter of detached well and what is the HP and diameter of the lift station. Please get me the info by next week so we can get the insurance certificate taken care of. Thanks a bunch Judy • From;Kate Tioaina At;Landmark Insurance Services FaxiD:651-464-7596 To:Judy Date:5272004 12:37 PM Pace; 1 of 3 Phone: (651) 464-3333 ext. 209 Fax: (651) 464-7596 ext. 6514647 • Fax From: Kate Tipping To: Judy Pages: 3 Fax: (651) 439-0574 Date: 5/27/2004 12:37:51 PM Phone: ( ) - Subject: Email address Message: Here's my email address to send the lift sattion info to. Thank you. f • From:Kate Tipping At:Landmark Insurance Services FaxID:651-464-7596 To:Judy Date:5/27/2004 12:37 PM Page:3 of 3 Page l MEMO Landmark Insurance Services iTAIMMASYMISIMMINAVINKSWERSOISSIZOMMINDIA 232 South Lake Street OAKPA-1 bT 05/27/2004 Forest Lake,MN 55025 A°� ° « d i + � u 1/11, Phone: 651-464-3333 Fax: 651-464-796 ip 0, r,=�.. .".r CMC24118 CP 07/07/2003 07/01/2004 City of Oak Park Heights Eric Johnson,City Admin. 14168 Oak Park Blvd PO Bx 2007 Oak Park Heights,MN 55082-6476 ;: y},.5:- ".... p i' tl"WOPITO# 7 6 �i"i iY3 ?� '.' � r r a„`Y £t r! ,..r . . ._• :: .,,""a", . : : �fF�= ,RS �r 'f K , .Yprr �� ..1 "?A7 21/4"d, it ith rf.'. .1�f�J�a�rt��s��t� Nird a"d�a,f�.!�a1tla:c? r...�,.r.; r.Xi . at st,�lig My email is balm @landmark-ins .com. Thanks ! Kate Tipping • • 05/19/2004 WED 09:29 FAX [ 001/004 MAY-18-2004 06:49' uhiAuU UI- MN C:1 I lk.5 651dtilldWW 1-1,161/1e4 FAX TRANSMISSION • League of Minnesota Cities Jnsurancenust 145 Unhersil�IAvenue West St Paul,MN 66103.2044 (651)281-1200 •(800)925.1122 I..qP�.�Atw Fax.(661)281-1298•TOD:(861)28112.90 Oho p,o...u.g...16.nr www,Imnaorg To: Kate Tipping From: Tracy Nesburg—Appraisal Coordinator Landmark Insurance Services LMCIT UndenNriting tnesburg @Imnaorg Fax Number: 651-484-7596 Phone Number:651-281-1212 or 800-925-1122 ext 1212 Date: 5/17/04 Total Pages: 4 Subject: Oak Park Heights •Comments: We are still in need of the attached appraisal information. It is extremely important that this • information is returned to ensure that each building has adequate coverage. lithe city feels their buildings have adequate coverage and an appraisal is not needed,please reply to this fax with that response. If the city wants the building appraised,please return the attached information request forms as soon as possible. 40t. v- 19-oy 9-J eve addressee. If you did not receive all of the pages in good condition, advise the sender at your earliest convenience. N EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER ((35 — CS/4- 05/19/2004 WED 09:29 FAX [6002/004 MAY-18-2004 06:45" LhMUUh u►- MN LI l l t� e 1 i11Gyti h Odd/YJ4 eta September 5,2003 Landmark Insurance Services f p Agency Contact:Kate Tipping Phone: 651-4643333 e.Ct Fax:651-464-7596 I�Q� City Contact:Judy or Eric Johnson, City Administrator Phone: 651-439-4439 Re: Oak Park Heights Dear Kate, LMCIT provides appraisals as a standard service to LMCIT members. The actual appraisals are performed by Maximus,a professional appraisal firm that LMCIT is using on their behalf. Maximus will perform on-site appraisals on locations with replacement cost values of$500,000 or greater and desktop appraisals on locations with replacement • cost values less than$500,000.Mobile property with a replacement cost value greater than$25,000 will have a desktop appraisal.Property in the open will not be appraised. This service should eliminate the need for further professional appraisals of the city's buildings,contents and mobile property.However,we recommend that the city review their values at each location to make sure that they appear to be reasonable.Please contact LMCIT if you need assistance. The recent change in the property coverage does place a limit on the amount of coverage available at each location. This limit is 150% of the estimated replacement cost figure as shown on the Schedule of Covered Property. The new coverage applies to each city at their first renewal on or after November 15,2002. During year 2003,LMCIT will automatically perform the following appraisals: • Initial appraisal on the city's property,if not already completed. • Additional appraisal on locations that the city purchased or newly acquired since thcir initial LMCIT appraisal. • Additional appraisal on mobile property with a replacement cost value greater than$25,000 that the city purchased or newly acquired since their initial LMCIT appraisal. • Additional appraisal on those locations with a replacement cost value greater than $5,000,000 that were newly acquired or purchased during the current year. • 05/19/2004 WED 09:30 FAX QI003/004 'r1AY-18-2004 66:491' LJHUUt IA- 1N L! I !t5 bb12d11d N.UJ/b4 . If the city requests,LMCIT will perform additional appraisals on the following: • Locations with historical values. • Locations with unique architectural features. • Locations that have had major building renovations since the initial appraisal. Below is the current status of the city's appraisal and what needs to be done to complete the appraisal process. The goal is to complete this appraisal process during the year 2003. If you have any questions,please contact Tracy Neshurg,Appraisal Coordinator at 651- 281- 1212 or Mike Wozniak,Underwriting Manager, at 651-215-4090. Fax Number— 651-281-1298. We would like to develop this information within 45 days. • Initial appraisal was completed on the locations or mobile property as per the schedules submitted. • The covenant was endorsed and a copy of the appraisal in a spreadsheet format was sent to the agent and city. • We need to perform appraisals on those locations or mobile property that were not pert of the original schedules. • In order to perform the appraisals,information is needed on the locations or mobile property indicated on the attached forms. • Please obtain and send us this information. • After we receive this information,an appraisal will be performed and the • covenant will be endorsed. A copy of the additional appraisal in a spreadsheet format will be sent to the agent and city. • This will complete the appraisal process. • • [ 05/19/2004 WED 09:30 FAX 7)004/004 b12bIl'eVW h.W4iitica MAY-18-2004 06:49. LtHUUt Uh MN cilim .. , t , , . „ 1 , , , ! flir, tiri • ' . , ; ■. ; , 1. ; ; , : 0 Iii II ' ', illi ! 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'1 : :, : ' dti. 1 li I, 1 ' : : ' , ', , , : ! iIli • ' 1111 /. ! ' i ; ;" '• ! . ; ; CHICI. IIIMII : i , , .. . . • i*Vi II . 1 ; 1 , . • tiz i .: '. .. iii ! ■ :. : 111, ■ ' . .. i. i • . . .i . i1WIli • ' • ■ 11, iiiill' . 1. '' • H .:: : : • ; Will ; . ' ii• ! HI ■ ji ' • itii ". ; 11iiiiiil • . 1 : 1 } 111 . • ' ■ ! ! !. ' 1 .1111 .1 "■ ■ iill • i , ; ; i ; ; . . ; . ,_; . 1 .. . . • ,„... 11 , 0 TOTAL P.04 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST d� PPS LIABILITY COVERAGE —WAIVER FORM • Cities obtaining liability coverage from the League of Minnesota Cities Insurance Trust must decide whether or not to waive the statutory tort liability limits to the extent of the coverage purchased. The decision to waive or not to waive the statutory limits has the following effects: . If the city does not waive the statutory tort limits, an individual claimant would be able to recover no more than$300,000.on any claim to which the statutory tort limits apply. The total which all claimants would be able to recover for a single occurrence to which the statutory tort limits apply would be limited to$1,000,000. These statutory tort limits would apply regardless of whether or not the city purchases the optional excess liability coverage. . If the city waives the statutory tort limits and does not purchase excess liability coverage, a single claimant could potentially recover up to$1,000,000. on a single occurrence. The total which all claimants would be able to recover for a single occurrence to which the statutory tort limits apply would also be limited to$1,000,000., regardless of the number of claimants. . If the city waives the statutory tort limits and purchases excess liability coverage, a single claimant could potentially recover an amount up to the limit of the coverage purchased. The total which all claimants would be able to recover for a single occurrence to which the statutory tort limits apply would also be limited to the amount of coverage purchased, regardless of the number of claimants. Claims to which the statutory municipal tort limits do not apply are not affected by this decision. This decision must be made by the city council. Cities purchasing coverage must complete and return this form to LMCIT before the effective date of the coverage. For further information, contact LMCIT. You may also wish to discuss these issues with your city attorney. • We.Pcwtt(- c1 5accepts liability coverage limits of$ t 1000 000 from the League of Minnesota Cities Insurance Trust(LMCIT). Check one: ❑ The city DOES NOT WAIVE the monetary limits on municipal tort liability established by Minnesota Statutes 466.04. The city WAIV the monetary limits on tort liability established by Minnesota Statutes 466.04, to the - ent .rthe limits of the liability coverage obtained from LMCIT. Date of ci ou i sting '" 24 ° 03 Signet Position & athinithl 5�z,1 V Ave.Return this cornp�ted form to LMCIT, 145 University A e. W. St. Paul, MN. 55103-2044 LMCIT(11/00)(Rev.11/03) Page 1 of 1 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • 145 University Avenue West St. Paul, MN 55103 (651) 281-1200 APPLICATION FOR: i?i'tzij aF OiLL 7411t-- _ ki+ County: Vhsql( IF i Mailing Address: j- (( a� ,..vk_ :i VW Phone: kIt?J _ City, State, Zip: (kv —+ ( VS,M� �✓ 8.� - Contact Person: (' E� c Vv"pc,"""s ei/—i a ,I I D�'ov . ������' , v� Title: /� (J / 2000 Census Population: , 2 1 Current Estimated Population: '/J21 i Total Expenditures All Operations: /%;, 1/ ':s 4-; . - -- Is the applicant a Member of The League of Minnesota Cities? Yes FINo n Submitting Agency: / dmai F-� _Z1/ AVZ `Cc. •3&' `' (e • Address: T3 2.-- `, . rgk Snedh City, State, Zip: g (-4.-1t-1 �'` 1\--\ `��✓"'�' Telephone: (1/51 `1 3 Facsimile: C4 q`7-- Agency Contact: (C_ .--c. 1-,00/19 Email Address: Date of Council Resolution or Contract Appointing the Agency: AGENT COMPENSATION: M 10% City Will Compensate the Agent Directly - ❑ Other Please specify: Standard Deductible: go (Applies to All Lines. Optional All Lines Deductibles are Available.) Current Information on Coverage You Are Applying For: Carrier Policy Type Expiration Date Premium L MC- 1 i7 .Ck -7/7%4 • vii L e o / ltrk,19/a m L/56 LMCITAPP(11/97)(Rev. 11/03) Page 1 of21 • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PROPERTY/MOBILE PROPERTY COVERAGE • The General Limit of Coverage per Occurrence is the sum of the estimated replacement costs of the building, contents, property in the open, builders risk property, and mobile property. BUILDINGS/CONTENTS/PROPERTY IN THE OPEN Attach updated schedule of buildings/contents, and property in the open. Please identify any vacant properties on the schedule. MOBILE PROPERTY -GREATER THAN $25,000 Attach updated schedule of mobile property with replacement cost values greater than $25,000. 1 MOBILE PROPERTY - $25,000 OR LESS Mobile property with replacement cost values of$25,000 or less an be covered with no schedule. There is a flat premium charge. Do you want this coverage? YES ONO CRIME COVERAGE The covenant automatically provides a $100,000 per occurrence limit for crime losses,with no additional premium charge. LMCIT provides coverage for theft, disappearance and destruction-inside, theft disappearance and destruction-outside, and forgery and alteration. The coverage is now a blanket limit with no location limitations. If you need additional limits, please contact your LMCIT Underwriter. LMCITAPP(11/97)(Rev. 11/03) Page 2 of 21 h • N 1 N NA m a ' 0. `.. N. i ..� `♦ y Y CO ° > Z- ., '" o 0. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 N N u O U o 0 0 ," N U o C I U• M �L Z Z Z Z Z z z Z Z Z z z z z z z Z Z Z Z Z Z ..1 0 O. Y .i 0 H 1 O N • ".. O. a �. a mo CC AZ m NI. CC s a m o: cc s o: o: o: ax cc CC oe Z Ce oe CC N O O Z S U LL S Z LL LL "! LL U. LL S Z Z Z Z Z Z w u \ 9•W O N 0 Q N M 10 .4 N N . N N N M CD N a in N 00 .F 0 0 •t M o .4 LA .4 Co N 4 an M in in .y a0 as %a .� 00 .t W DI L .t c O %e 0 W N N M "0 N0 "O "O M '.0 .4 T O ~ 0,&4 i U L N CO No , .i. .4 4 M 00 e O a. 04 on Ml N d on M U1 IA a U o! 0 N .N4 �/� 0 N it) '.0 at 00 00 W W WO N M . %0 in• FH 8 W .i 1 0, a W • • O ] O J Z J 0 0 0 O F- O J Z J 0 0 0 0 Of 0 0 0 0 0 0 0 O W 0 I- CO U m 0 CO CO 0 0 0 0 00 m 0 0 0. O. O. 0. 0. a. 0 A d Q. U 1 a O .\ \ L. J N - ` Na < F Z Z \ Z Z M Ut' 0 W 0 0 lee O Q W 0 Y Cg O DC /2 01 J c4 0C O O. J H 1- IM a N N < < J Q Z m Z Z N < 00 O. 0C W et 0. Y .0 Y Z O Z Q O A. Y 3 Y DD W 0C W CC H ^ 0C Z Y W H O H Z H 0 0 Y W De 0 A J 3 0 3 Y < F- 1- N Y Q O CC H 1.- F- F- 0C Y J < 0C H Q W W E O J < 0 Z 0 Q 0. Q 0 0 0 O. H < > < W Q W Q M Q J a. < > 0. N •.0 O. 0 1- C N S 05 W W U- S W 0C Q W >. U 1F F7 D - 0 S m >. l�a( 3 7 • 7 L Y 0 W S W V J Y 1- N 0.. W J 0 OWC. W J J F- 0 1- * H O b > 0 Y W Y J Y Y Y Y H A. .4.4 U • H .4 < CO~ Q .4 PI IU S CC H M .4 S S W O S Q H W H H .4 .4 H 3 < C>Q < < < OWC < H < o O Q U .i 3 H1 3 .i N 0 J N 0.. .•1 W N 0C U N > J CO J N J .i .i U U) O. U 0. > O. 01 • U > a. 0 0 0 'p .i .4 .i .4 .1 .4 .4 .0 .i N .i .i .i H H H .i H G S \ .i 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 U.) o CO ZZ Z o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Cg U 0 0 .i N M .4 in NO N 00 ON 0 .4 N M .4 N 0'. N 00 0 Z S O 0 0 0 0 0 0 0 0 0 .-1 N .i .i .i ..4 •1 .4 .-1 H J Cg J 0 0 0 0 0 0 _ 0 0 0 0 0 0 0 0 0 0 0 ,0 0 • o M H 0 01 O. i+ C 0 0 00 0 .• O G. 9 N 0 O N N 0 0 U - O •••• o V o Y W C O• M L Z Z Z •.i 0 0. Y .i o ul 1 • r� O N 0. N o V t1 Z E I- W G4 .. V I- x O W Dl t a N W4 C..) a ou, � M v� U > • N Vi N 01 L V] U W b w • m -,��E. 44 ' ti ° - O x UI- um d Po U 1 co m W I 0 4 w s C 11 Z .J .•1 V N 0:1 O o Ng 143 Y LL O ul M 01 0) O. 0. 0 N .- Z C J J N W J J •N 0 VI r IW •0 a o 3 4a<0 0 0 •p • o (I) d co Z .i .•- 0 0 O. o C 0.• •• J• C J Z N N LEAGUE OF MINNESOTA CITIES INSURANCE TRUST WATER AND SUPPLEMENTAL FLOOD COVERAGE APPLICATION • 1. Does the applicant have any locations in a flood hazard area? If yes, has the maximum amount of NFIP flood insurance coverage been purchased? 2. Please provide the following information for any location where you are interested in the NFIP Supplemental Flood Coverage from LMCIT. Note:NAP flood insurance coverage must be at the maximum amount of insurance available for the LMCIT Supplemental Flood Coverage to be available. Please contact your Underwriter for further information. F1iu�%7 N57.'- 5 .t 1 W v77JJ i 1 1 '6 5 1 1 r E ke, -a,tI 7fAgsP a �f� �" r � of r Yt t,;: xt, tiw , f r f. �. r .._ �u�r.. r.7�v.a.,�r..,���,.:.�..�._._ee_�'..__„J".�.�::�:.L.i:.st,.z.y^-�cc,�X�e52.'.,;�u..-�..r�.�ss,....: sz,...u..�i.C...�s . c�ae�wt�...y.�C�s��avA..�..�y.�_—..�-t_,.�,�.u��� �.��.w�e:.�... • ■ _- ■ ■ • LMCITAPP(11/97)(Rev. 11/03) Page 3 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST WATER AND SUPPLEMENTAL FLOOD COVERAGE APPLICATION • 1. Does the applicant have any locations in a flood hazard area? V If yes, has the maximum amount of NFIP flood insurance coverage been purchased? the following information for any location where you are interested in the NFIP Supplemental 2. Please provide g Y P Flood Coverage from LMCIT. Note:NFIP flood insurance coverage must be at the maximum amount of insurance available for the LMCIT Supplemental Flood Coverage to be available. Please contact your Underwriter for further information. .ua ' ,, `1"«!, .t k 4 �X'�y.J'7 I w r Yt r w1 3.t a����tF��C r�2ii 8 r i,✓t Fri_x4`r`+ T� '77 „ ilttro w S uxte � avl # 4��yiY! �' ` If o r v. .ax t ■ • ■ ■ ■ ■ ■ ■ ■ ■ ■ • LMCITAPP(11/97)(Rev. 11/03) Page 3 of 21 • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PROPERTY Unless specifically named, the following entities are not covered for property coverage. If property coverage is desired, please indicate below. If any of the entities have property coverage elsewhere, please provide details below. HOSPITALS OYES ONO D' /A NURSING HOME OYES ONO 1:1 N/A HEALTH CLINICS OYES ONO 0/A AIRPORTS OYES ONO 9N/A ELECTRIC UTILITY OYES ONO fN/A GAS UTILITY OYES ONO KW/0k • STEAM UTILITY OYES ONO 1;2[N/A HRA ❑YES1O EN/A EDA AYES ENO ❑N/A PORT AUTHORITY OYES ENO ►! /A ADDITIONAL INFORMATION: • LMCITAPP(11/97)(Rev. 11/03) Page 4 of 21 r a LEAGUE OF MINNESOTA CITIES INSURANCE TRUST INSTRUCTIONS FOR LMCIT EXPENDITURE WORKSHEET • Line I All expenditures—include all operating expenses, capital outlay, capital projects,debt, service (principal and interest)for the following: General Fund Debt Service ,2, yS�S /u�"b yL�,33 C• Enterprise Fund / zS0 Port Authority Revenue Funds / 5 atr Nursing Homes Capital Improvement Funds Hospitals Y / Er53 Airports Clinics HRA N Other(please describe) 4, EDA Line II Transfers Out Line III Please list the expenditures for the categories shown on Lines III. a—i). These expenditures may be deducted if LMCIT is NOT providing E &0 Coverage for these operations. Line IV Adjust total expenditures is the total expenditures for those departments and operations that have E&O Coverage with LMCIT. Line V GL Deductions: A. Please list expenditures for the categories shown on Lines V. a—m). These deductions are necessary to subtract expenditures for operations or departments where the exposures are individually rated. B. Work performed by contractors which includes capital projects or services are also subtracted. For Your Information a) Contracted Services—All Operations: Expenditures should be deducted if the services are provided by others and they provide a Certificate of Insurance. b) Debt Services (principal and interest) c-j) Please indicate expenditures for these operations (minus contracted services and debt services) m) Special Deductions: There may be some special deductions that are appropriate. Please list these special deductions or list them with your underwriter. Line VI The operating expenditures are the expenditures that will be used to develop a portion of the liability premium. Individually rated exposures are used to develop the remainder of the final premium. PLEASE ATTACH A COPY OF THE LATEST CPA AUDIT AND/OR THE PROJECTED BUDGET(WHICHEVER REFLECTS THE EXPENDITURES ON THE WORKSHEET.) THIS INFORMATION WILL ASSIST UNDERWRITING IN ANSWERING ANY QUESTIONS WITH REGARD TO THE EXPENDITURES WORKSHEET. LMCITAPP(11/97)(Rev. 11/03) Page 5 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST LMCIT EXPENDITURES WORKSHEET • 1 Applicant: l� es e. 06a- gf. ` ��'\ Budget Year D--QQ 1 All Expenditures ,t./ 5-"t7 %c II. Transfers Out // .1?.7 a 30 // III. E&0 Deductions a) HRA b) EDA c) Port Authority d) Nursing Homes e) Hospitals f) Airports g) Clinics h) Utilities(Water, Electric,Gas and Steam) i) Liquor Store Cost of Goods Sold(if included in l.) IV. Adjust Total Expenditures(E&0) • V. GL Deductions a) Contracted Services /, 4194, /6",3 b) Debt Service y6 R., 3340 c) Water Department Only °?2-iGr 3 qs'/ d) Electric e) Steam f) Gas g) Liquor(Operating Expenses Only—Do Not Include cost of goods sold) h) Recreation Buildings(Arenas,Sr. Citizens Centers,Ice Arenas) Swimming Sw g Pools j) Golf Courses 0 k) Individual Purchases which exceed 5%of the adjusted total expenditures (E&0)(List&Describe) I) Operations or departments that have E&O Coverage with LMCIT, but have their own General Liability with another insurance company. m) Special Deductions(List and Describe) VI. Operating Expenditures(GL) �j v 41 Cl 41 75' LMCITAPP 11/97 Rev. 11/03) Page 6 of 2i LEAGUE OF MINNESOTA CITIES INSURANCE TRUST MUNICIPAL LIABILITY— SEPARATELY RATED EXPOSURES I DO NOT LEAVE ANY SPACES BLANK IF NO EXPOSURE PLEASE INDICATE N/A OR NONE Applicant: e--(f71 . - Uvii k 1 Date 6// oi/ 1. Golf course annual receipts: YA - Number of golf carts rented out: _ 2. Street mileage: (Round to nearest mile, i.e. 4.2 miles should be 4) 3. Area (square feet)of Exhibition Buildings, Recreation Centers,Arenas,Auditorium or Community Centers: vr'e. 4. Water Department payroll: / P0, 6"4710 • Total gallons of water pumped annually: �3�� 300 pu a (Round to nearest million, i.e.2,500,000 should be 3,000,000) 5. Electric Department payroll: 6. Gas Department payroll: 7. Steam Department payroll: 8. Number of powered boats: Horsepower and usage of each: w9. Number of boats and canoes not powered: Explain hc;w they are used: LMCITA.PP(11/97)(Rev. 11/03) Page 7 of 21 • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 10. Municipal liquor store receipts: P q p • Store 1 Store 2 Store 3 On Sale Off Sale 11. Number of seasonal swimming pools: Height of diving boards: 12. Number of inside swimming pools: Height of diving boards: 13. Number of swimming beaches: Height of diving boards: Number of docks and rafts: • 14. Number of water slides: Heights: Length Location: Seasonal: Year Round: 15. Does the pool(s)comply with the Minnesota Department of Health revised Chapter 4717, Public Swimming Pool Rules effective January 4, 1995, concerning water depth requirements for diving boards and pool decks? Yes❑ No❑ 16. Number of staff attorneys: J \"�` Do you want coverage to be excluded? Yes❑ No❑ Additional Information May be Necessary 17. Does the Applicant want to exclude medical payments? YesO No )(/ • LMCITAPP(11/97)(Rev. 11/03) Page 8 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST MUNICIPALITY QUESTIONNAIRE • DO NOT LEAVE ANY SPACES BLANK, IF NO EXPOSURE PLEASE INDICATE N/A OR NONE /d/ /e'-(-.' Applicant: 1)g�I "" --1-161:9\ 1115 Date 1. Does the applicant own or operate any of the following? t t i r i vr"�y ? s'. x�: �G` F:"" 5 � k"II'�,.5'° �; {}'"`i ' 7 yyYa''. �^'" " r, „f'.. °c�— r-•� � 1 ��i 4 '�r � � 7� M m, � i4 ■ . �7 � 11 t l.. � � a � ���f 1�����y.+Y� f f�_kl.�.".� ■ l� ft y..}°.�;;,.� ,.9'n .y C 1 f �} ,'�t�. ��•Yr .fro '.r-�y j ,��r r{I,� l''',7141(:' -, ) 1'.f flip ' io �Y_ lam"r :1 r{ ��-�IA�:,E,6:��° R1��F ��,t, 1 ' r ,',',',^�7 ll�ir,01A." .°.%1!�,,1�1d ''°"b 1l)r � ��3 !'lo,t .t° � ��o,f1$ �I��r�:'1917pn:'i ,_ ��'`!.i'7�..�°:�v/���jr'�IE.I�A��K� ;x��`A�Y. F..F` �-��A �°�.t� p.�4*f�VV-� ' a �ti.���� r kJ 1�� � 9 r o �o--yy;;�,� I; :Fo� u�p��^,. I�°�LLA�, ir[ i / I- R7 rjl to i Ai tNP: � -1- ';''''. , - -` r^^. J c ' e i 1 ' i 6 `; ,.sd� ..._. S X�ss�.in. .,�;r.,a�,� u,l�e.va .a . _ �;.lwl....,...u.�Y'`.�s,.v d�tf.:r.-. ...�ue. 'sv_. ,� .�im tiaJ..,. Hospitals • ❑ No Nursing Homes E No ■ ❑ No - h Clinics ❑ Yes \, No ■ - • No WM A -•rts ❑ Yes j No Milin ❑ No Comments: * Municipal Liability, except for bodily injury, property damage or personal injury, is automatically provided for the applicant and the other Governmental Body .or Entity. If you do not want coverage please notify LMCIT. ** These questions are intended to analyze the coverages provided by the other insurance companies. These other policies must provide bodily injury, property damage or personal injury coverage to the applicant and the other Governmental Body or Entity. i , _ LMCITAPP(1 ii97)(Rev. 11/03) Page 9 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 2. A. Damages arising out of the following activities are excluded unless such board, commission, authority, or agency is named in the Declarations, in which case the city will also be covered to the extent of coverage provided under this covenant to the named board, commission,authority or agency for damages arising out of the activities of the respective named board, commission, authority or agency. Please designate the activities you want covered below. B. If the Governmental Body or Entity has purchased coverage elsewhere the City needs to evaluate their exposures and the coverage that they need. 1) Is the city named as an additional insured on the other policy and for what coverage? 2) Does the city want coverage from LMCIT for these activities? PLEASE CONTACT LMCIT FOR ASSISTANCE. ADDITIONAL PREMIUM MAY BE NECESSARY. r 7:77, t.°3.011* ' TWag:71,1 ',C$11,941, 1■17 ,1/4- ,iP,40r1Cik.61fWY 11'1'ft-Y`.0".i.-'-0"1' Gas Utilities Commission El Yes No Questionnaire Electric Utilities Commission 0 Yes 'No Questionnaire Needed Steam Utilities Commission 0 Yes WAI No Questionnaire Needed Port Authority 0 Yes Oa No Need Full Details H. g & Redevelopment Authority 0 Yes , No Need Full Details Economic Development Authority MI 0 No 0 eed Full Details Al 3 0(2 Area or Municipal Redevelopment El Yes 0 No Need Full Details Authority Municipal Power Agency 0 Yes 0 No Need Full Details Municipal Gas Agency 0 Yes 0 No Need Full Details • LMCITAPP(11/97)(Rev. 11/03) Page 10 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 3. A. Damages arising out of the following activities are excluded unless the agency or board is 411 specifically named in the Declarations. Please designate the activities you want covered below. B. If the Governmental Body or Entity has purchased coverage elsewhere the City needs to evaluate their exposures and the coverage that they need. 1) Is the city named as an additional insured on the other policy and for what coverage? 2) Does the city want coverage from LMCIT for these activities? F..*b'i�+r..::x.,.k.;...:tt....`._..:.k_._s...1W �;ua.1 i"•.,dY+va.`h'r."�r .t i.�-; . g..(J.t,...,. _a '1bx'">a ryl d�z6l:v9!1"S`'.Y� �1.�.C.`...S+lu. 11 ,- —a ;1— :7" ;1-4 I ; R 4,JrYr 4,w 6: 51yy . ��o a , :1 "(� tif ° 415),4410 +R r ; ry t',IF��4!;P,W, It,J) 9 Welfare or Public Relief Agency ❑ Yes No Need Full Details School Board ❑ Yes [ No Need Full Details 4. Does the applicant operate a dump or landfill? 1 What type of material is deposited there? Is the area fenced to keep out the public when closed? Is the area attended during open hours? Does the applicant own or operate a marina? • If operated by others, please indicate and advise if the applicant is named as an additional insured on their policy and the policy limits provided. Is coverage desired? Yes ❑ No ❑ If coverage is desired,full details must be submitted. i LMCITAPP (11/97)(Rev. 11/03) Page 11 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 6. Dams classified as Class I or Class II by the Commissioner of the Department of Natural Resources or • any dike, levee or similar structure-(Failure or bursting is excluded.) dt(OL-- A. Age of Dams: Inspected regularly: Yes CI No ❑ l By Whom: Height of dam above reservoir: Height of dam above the bottom of spillway: Width: Is the dam fenced to keep the public off? Acre feet of water dam has been designed to retain: acre feet B. Age of Dike or Levee: Height of Dike or Levee: Construction Material of Dike or Levee: Acre feet of water Dike or Levee has been designed to retain: acre feet Who built the Dike or Levee? Is the Dike or Levee inspected regularly? By Whom: 07. Describe any large construction projects anticipated for this coming year. 8. Parks and Playgrounds c A. Description (including area)of each park or playground: �� a, &I, B. Description of playground equipment on each: • LMCITAPP(11/97)(Rev. 11/03) Page 12 of 21 0, LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 9. Does the applicant operate any aeration devices in the winter to keep an area of local ponds,lakes or • rivers ice free? If so, please give full details and precautions taken. 10. Special Events/Risks Coverage is excluded for several Special Events/Risks. Please review your covenant and contact your LMCIT Underwriter for additional information. Optional coverage may be available. Does the applicant own, operate or sponsor any of the following? If yes, please provide details. A. Automobile, mobile equipment, snowmobile or motorcycle in any racing, pulling or speed or demolition contest or in any stunting • event. This would include go cart tracks, mudder courses, tractor pulls. (Excluded) DYes kNo B. Amusement devices,with a power motor greater than 5 H.P (Excluded) Dyes fONo C. Beer booths(Liquor Liability is excluded. Refer for consideration) DYes No D. BMX tracks C1 Yes o E. Climbing Wall ❑yes _pNo F. Dunk Tanks ['Yes Sallo G. Festivals, parades and exhibitions Dyes fNo H. Fireworks (Excluded. Refer for consideration.) DYes Wf'No I. Rodeos (Excluded) DYes 11No J. Skateboard Parks DYes qNo K. Ski jumps, ski lifts and tow ropes DYes 'lo L. Toboggan or Tubing Slides Dyes o M. Trampolines DYes No If any of the above are operated by others, please advise if the applicant is named as an additional insured and the policy limits provided. (Continued next page) LMCITAPP(11/97)(Rev. 11/03) Page 13 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 10. Special Events/Risks (continued) IDDetails: 11. Firefighters y -1 fc a- F L 117D14 c r�611 ,f- Payroll of paid firefighters: Number of volunteers: Number of fire trucks: /A/ty' -- Describe any fund raising activities or celebrations by the firefighters or relief associations: 12. EMT's and Paramedics Number of rescue trucks: Number of ambulances Number of emergency runs: Number of convalescent runs: Number of EMT's: Number of EMT-A's: Number of paramedics: Is there radio contact with hospital doctors? Describe any EMT type losses: • LIvICITAPP(11/97)(Rev. 11/03) Page 14 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 13. Law Enforcement Total law enforcement payroll: (q,31 c� [w Number of law enforcement vehicles: I Number of Employees by class: Class A(Full-time): A(Part-Time): Class B: C Class C: Class D: 0 Class E: 0 Class F: 0 Description of classes. A=Armed with arrest power B = Unarmed, no arrest power C=Non-officer employees D=Auxiliary police E=Voluntary unarmed F=Voluntary armed Describe any law enforcement type losses: , AIY" e---- • Describe any jail or detention facilities maintained: LAM- (9. ` ( C Maximum holding period: as al/avid 14 - /a4 v � 14. Grandstands and Stadiums /7 ���i� A. Number and location of each: / -1 r k..&e P61& (p , -m c141 61—ackers) B. Seating capacity: /1'0 C. Type of construction: '--G If ( UryrLti D. Permanent or temporary: fUiVi e 15. Wharf or Docks-Describe: r\' LMCITAPP(11/97)(Rev. 11/03) Page 15 of 21 ri LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 16. Street or Road Construction or Maintenance 3 / Annual expenditures: / � / 35 � How much work is sublet to others? Ca( ���f" Are Certificates of Insurance obtained indicating adequate limits? 'yes Is any blasting done? VI b 17. Please describe any contractual,agreeme is the Applicant has entered into such as: A. Mutual aid: vac. l, 49111 ( f B. Police or fire protection: L () C. Other. Describe: 18. Joint Powers Boards are not covered. However,they may be considered for coverage by submitting full details in a separate application. IMPORTANT! Coverage is not bound or in effect until you receive • written acceptance from LMCIT. 19. Do you routinely get Certificates of Insurance from all independent contractors? t P� 20. Does the applicant provide a fire alarm or burglar alarm protection stem? fe-C if so, please give full details. 1ih hityv / S W1 Y zd vy air> ail t 01/1 1/r/Ploter i,,1 CLAt . 'two 1 Ct.rti,A t S N" Y bui G?<< 44'1 • J 21. Any other pertinent information not covered above: • LMCITAPP(11/97)(Rev. 11/03) Page 16 of 21 i ie, LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 22. Applicant was created in: / (Year) • 23. Names and official titles of the Members of the Board or council of the applicant: Name Official d)a►.%/4 c�. -t c..0 el ' d i/ Les 4b rc,..h&wlsvK 11 It • S o_f, Dc .e err cab/)G1 f /21-e.l'V ' 'V liar cf Vac Co• - ( --c r, _ t 1Lt I'l ail j 11 civil/4 fr A('k S Li 5 enSc'/'t CO CLrt .,7 142Y/n,a.ei-+ 24. Fiscal Year *Revenue *Expenditure Fund Balance At Year End 20 014 Projected Year Y,363-.57r '97, 6 9 73�, 1 y3 20 03 Current Budget (,,2,2 dg/ q�'l%�s 2- g (,Y „ 01 '7 20 02- 1st Prior Actual tJ CA 2 1120 e65-90/77 1 il- O1 7 2-0 20 01 2"d Prior Actual 11 2400i2J-6 '�� Li,'72( ttt tI /4, OC7 <? • 20 G1 3rd Prior Actual I-CM//t02lr —I)X01/044(€' (p, LW 11)-774.. *These figures should include all funds including governmental, enterprise, miscellaneous special revenue and debt service funds. If desired, you may send photocopies of appropriate sheets from annual financial report. 25. a. Total amount of outstanding bonds: 1� O e,4 4 00 b. Latest Moody's and/or Standard and Poors' bond rating: A _ MOD cict • LMCITAPP(11/97)(Rev. 11/03) Page 17 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 26. Have any of the following situations occurred within the last five years? • a. Appropriation or condemnation for which agreed 9 settlements have not been achieved. DYes No b. Improper or alleged wrongful granting of variances, \ building permits or similar grants or zoning disputes. DYes f No c. Wrongful or alleged wrongful approval of building plans, designs or specifications. DYes .]No d. Wrongful or alleged wrongful approval of building construction. DYes ,No e. Allegation of unfair or improper treatment regarding employee hiring, remuneration, advancement or termination of employment. DYes No f. Disputes involving integration, segregation, discrimination or violation of civil rights. DYes No g./ Any grand jury indictments of any public officials. DYes ,.No h. Assault and battery claims made against the municipality or its officials. DYes [ylo i. Any riot or civil commotion in the past five years. DYes (y No j. Any losses or claims occurred involving contractual disputes. DYes No .27. Land Use Liability Number of building permits issued: c.B VS Number of variances: Granted 3 Denied 0 Number of conditional use permits: Granted Denied 1 ^ el..4 ),-e-e--a- _rt,a_rfat,Liwra,,,,„ c Cuz..�.4.w/ 07....re 28. H s the City submitted their Comprehensive Plan to the Metropolitan Council for review and comment? (� Yes E No lIIIIIHaas the Metropolitan Council reviewed the plan and made their comments? c V Yes DNo Are you a participant in the r ropolitan Council Livable Communities Program? [ 'es DNo What year did you join? / / /(r ll • LMCITAPP(11/97)(Rev. 11/03) Page 18 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • 29. Please list the additional covered parties required. '',;• " x ry 5^ "a g✓ )4'27, �1F 'f 2,zec....,�.w..�.:1 ADDITIONAL COVERED NAME ADDRESS PARTIES INTEREST . performing Contracts with a railroad and contracts with the contracto r perfo g the actual railroad construction project needs special attention. Please provide a copy of the contract to LMCIT. This does not apply to easement or side track agreements. Please contact LMCIT before you sign a construction agreement with a railroad or the contractor that is performing the actual railroad construction proiect. • LMCITAPP(11/97)(Rev. 11/03) Page 19 of21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST AUTOMOBILE LIABILITY AND PHYSICAL DAMAGE 0 &ill)Applicant: O&L ic4I _ 4 1. COVERAGES: A. Liability: Limit: $1,000,000. Combined Single Limit on Bodily Injury and Property Damage B. Do you want PIP coverage on the unregistered vehicles? ❑Yes ❑No This is an optional coverage. Please provide a list of unregistered vehicles if you want this option. C. Uninsured and Underinsured Motorists The standard limit is $50,000. Indicate limit desired. (1) ❑ $50,000. Uninsured and Under insured Motorist Limit* r (2) $1,000,000. Uninsured and Under insured Motorist Limit (3) Do you want UM/UIM coverage on the unregistered vehicles? Dyes ❑No This is an optional coverage.. Please provide a list of unregistered vehicles if you want this option. D. Automobile Physical Damage: The separate "comprehensive"and "collision" coverage options have been replaced by the new"auto physical damage" coverage that covers both collision and comprehensive. 0 2. Applicants have the option to make their LMCIT Liability Coverage primary for vehicles used by specified individuals or groups in specified circumstances. Pleasdicate if you want this optional coverage and provide additional information requested. Dyes No If yes, please indicate type of individuals or groups: If yes, please indicate number of individuals: 3. VEHICLE SCHEDULE Refer to the LMCIT Auto Coverage Changes bulletin included in your renewal packet. The applicant needs to submit an accurate listing of vehicles for the renewal. The applicant's premium for auto liability and physical damage coverages for the entire year will be based on the schedule of vehicles the applicant reports at renewal. A. All vehicles are covered for liability. _ B. All vehicles are covered for physical damage, unless you indicate otherwise. C. The listing of vehicles should include only those trailers with a load capacity greater than 2000 pounds. Smaller trailers are now automatically covered for liability and physical damage. D. Replacement cost is available for an additional premium on Fire Trucks and other high valued vehicles aged 10 years or less. (Indicate unit number and replacement value). E. Replacement cost may be considered for an additional premium on units aged 10 years or more with proper documentation of the maintenance history. F. Please indicate color of Fire Trucks 1=Lime Yellow; 2 =Red; 3=All Others (The attached computer printout provides the most current Schedule. However, recent changes may not show on the Schedule.) • LMCITAPP(11/97)(Rev. 11/03) Page 20 of 21 • 0 N O n < C W W > U 0 4 U a J J J J N a J .4 N a J J w J a a L O N S L O N S S O N L S O N L L O N z L J u U U a U U U a U U u a U U LI a u u u 0 U 4 Z K w I I- Z M 1171 O O Z u N Y = Z • J L CO z 2 Z 2 2 2 Z Z 2 2 2 2 Z 2 2 2 z z 2 2 2 W U 4 N J O W a 2 > W M N a 2 > W a J 4 > 3 W 2 w a J I- O O O O a O a a O O a O O O O O a O O O O 4 2 O o O O O O O O O O a O O O O O O O O O O > C• a 01 Ot 01 01 N N N al O O O O 17 n n n O O a O O 4 C J 01 Ot at O1 n n n n a O a a O m CO CO O O a O O Z a < al en 01 al N N N N N. N IN N n n el M O O O O CO = U > N N N N N n n n N N el .4 n n n n n n n n •O W N .d .I N N N N N N N N N N N .4 el el N .-1 •-• N < J a W CC LI v u Fu. .. 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"" ‘) ‘... .., . i- u FY S 1:1 I-I .- SW 4: . ■-.1 -.I 43 --I 12 2. U .4 .....,. X -- 0 0 e" L Lt o o 0.1., 1.2 u a ..a i a 4 j .., ....) a a t:j 5:3 6. I. ,+1...,4,, Cg 0 ,, 0 0 u1 1. 1.• C 0-1 U LI . ■-4 . . ... ■-■ lvk o L - S a z z '4 -.) u0 5 3 s < o o I- z x a u 0 ' 44,) el 6.u L,, '''o a a c i 1 0 0 S" I- U. U. 'Z'.I f:3 13350 C\I .... (.....r. Q 0 -I < U.1 I= rl II r.,*.V (.....1..„, Z4,„„ C‘. rst 0 .0 0 0 ...--' 0144 0 0 ‘,..7.S.' "....... I )- N N ....,. I..., ix "4. u -Lu 0 ,... Q ›. . % "%'4•1 ."'-Z..... 0 1 44 -4..„0.,.. e, a,.1 ...„ ” I itu l, S 5 VIa. , , , 0. 41110 .... ,_... ,In S 4- C 4-44 .-I 5 g Sul .4. • o a Is'g -... Lu .c ..-• 5 a. o C .... IA Id * Z ‹ C . 0 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST VEHICLE SCHEDULE ! r 7, ,, .,7,7- ,, c.'f'q' -. r1 d,,�7 '� - py+ 'f9 .. 7'r ?'�U ,, - f`t '-- S 4 .r,,/ l F-----777:—.7.7171 ,-e,7-c,-.--71-::i 1 - !•,; S L- t r j t i ! ! � E a�r-(('"e��..�'� yy 'r r�`1,11 -h t t F,` yqt. ' !f M t f, .0 . t b:..L� PYR , C'v=, t4 A' !''y -\ I1' r:. { r\t ���'LA S..' w � ,�e� a i r�, -1' t:� @ � "-. 7P�1���°.��f �! '.'�, q t t6t+ jj 'I�.,� P z 3' y�..yr ti n e f s- ! 5 ' U®9 t., fY.}'�v q,,rs;� y i t r Y.v'g .n '�'7'.1 ' 7 1. S,'�:Afi89140,AlA °� it,i °�:� .I' 4.<]x i F 31 A .4.4 �{ �^� �1�C t`' ,i1.R IP; - 6 Ott lAA0 1r ' 6`p "� ,.� t �j qtr S- } N r 1 1 9 3 q5! +,� _ mot(}n .l p ' 1.1-,;-.A.e if r �, `.,,,i,...,... .'f,r :. '.. }3 ,, l',„1„.„.',.-,.,,, l.,,,Z _1 t t ', v ,o ff ,..a _ f -A ,. �+L.-,i.X , 4�lq.ib,© 3 r!, q !f t >} A » �+ ° r r� H.,.‘,-,-', ',,,:,111,,:-!! {^ v vo ,y a >. r t'r� II- - i� + [ t `^>?� , h i S k,,,, ,, e"r{ 3 .F � . ' j F 1 4+ ,. k��+�.a,.vS•7..� f4 1.s�'�c.,�._..�...w� �«r�a,��Y�L�' .,,.'�.,s..�, 'j�'3 ...a.,.:Y_...,�, :� '?�:v�.�"�t+.�a�.�'�� ,c."..ifi'1 f 3: ��n,' `�'.�s.l.�..:�s..,.�:s �,1,.....:,__.u� � �,�,c� 1 2 _-- 3 4 5 6 7 - 8 9 10 13 -- 14 15 _ 16 17 _--_ 18 _- - 19 _- 20 -- _ 21 22 23 � 24 all LMCITAPP(11/97)(Rev. 11/03) Page 21 of21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PUBLIC EMPLOYEE EISHONESTY OR PUBLIC EMPLOYEE FAITHFUL PERFORMANCE COVERAGE APPLICATION • Limit of Corerveraae Per Occurrence: (Deductible) • Bond—Employee Dishonesty Coverage: $ (OQi w® (Standard) • Bond—Employee Faithful Performance Coverage: $ l0O O®CJ (Standard) • Option: The applicant may choose to have employee dishonesty or faithful performance coverage for specified positions. Please contact your LMCIT underwriter for additional information. � a . AUDITS: FREQUENCY: BY WHOM? CPA X , `,�1A(��1 STAFF AUDITOR UU OTHER(explain Fully) DATE OF LAST AUDIT: DISCREPANCIES DYES [ ,NO 3 1 --0 3 (If YES,submit copy of audit or auditors comments.) LOSS HISTORY: (LAST 5 YEARS) WILL THERE BE A SUBSTANTIAL INCREASE IN THE NUMBER I -- OF EMPLOYEES DURING THE TERM OF THIS BOND? INTERNAL CONTROLS: 1. ARE BANK ACCOUNTS RECONCILED AT LEAST MONTHLY? 'YES ❑ NO • /`, 2. IS THE PERSON WHO RECONCILES PROHIBITED FROM MAINTAINING BANK ACCOUNT RECORDS? V'YES ❑ NO 3. ARE ALL PERSONS HAVING AUTHORITY TO MAKE BANK DEPOSITS OR WITHDRAWALS PROHIBITED FROM EITHER MAINTAINING RECORDS OR RECONCILING THE BANK ACCOUNT? rES ❑ NO 4. IS COUNTERSIGNATURE OF ALL CHECKS REQUIRED? YES ❑ NO ADDITIONAL COMMENTS: • -I LMCITAPP.PEB(11/97)(Rev. 11/03) Page 1 oft , LEAGUE OF MINNESOTA CITIES INSURANCE TRUST CLASSIFICATION OF EMPLOYEES BY DUTIES OR RESPONSIVILITIES • . This classification under Class A, B and C constitutes the cities personnel as of the date of this application and should include Mayor and Council members. CLASS A EMPLOYEES All Executive Administrative Judicial and Supervisory officials,Department and Division Heads and Assistant Department and Division Heads.All Police Officers`and all officials and employees whose principal duties require them to: 1.) Handle,receipt for,or have custody of money,checks or securities,or account for supplies or other supplies or other property,authorize(or make appropriations for) expenditures;approve,certify,sign or countersign checks,drafts,warrants,vouchers,orders or other documents providing for the paying over or delivery of money, securities,supplies or other property,or serve process,or 2.) Maintain or audit accounts of money,checks,securities,time records,supplies or other property,or take physical inventories of money,checks, securities,supplies or other property. *Patrolmen are classified as'A"Employees under"Faithful Performance"Coverage but are classified as"C"Employees under"Dishonesty"Coverage. POSITI•N #OF OCCUPANTS" I N y f I POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS ill . f Lt o !mist- 1 a.':VYti n i. iCe ie 1 it,WWksbr Il it nititi i'S LI CLASS B EMPLOYEES 40 All personnel whose principal duties consist at 1. Inside or outside clerical activities; 2. Office work such as stenography,typing,filing,switchboard operation,business machine operation,etc.; 3. Operation of vehicles transporting passengers for cash fare or tickets. P SITIOLN #OF OCCUPANTS POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS CLASS C EMPLOYEES All personnel whose principal duties consist of 1. Skilled or unskilled labor and craftsmanship; 4. Any teaching capacity in the field of education; 2. Solely the mechanical operation of automotive equipment 5. Outside or field work of a non-clerical nature; 3. Non-clerical activities of the medical or nursing profession; 6. Patrolmen under the"Dishonesty"Coverage ••SITI•�' #OF OCCUPANTS POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS *;I, t.. c a. Soria • _l LMCITAPP.PEB(11/97)(Rev. 11/03) Page 2 of 2 k. LEAGUE OF MINNESOTA CITIES INSURANCE TRUST EQUIPMENT BREAKDOWN APPLICATION APPLICANT: 4 abk-- k 1-1e443 h4-5 , J Eh;c •S�(rtAson cs, INSPECTION CONTACT AT CITY: a ti��( 14o(se TELEPHONE #: 651-4(39-1/413`7 AGENT'S NAME: xctt-L -Ppeft vac, TELEPHONE#: (•5l -41 G Y-3333 COMPREHENSIVE (INCLUDING PRODUCTION MACHINES) NON-REFERRAL OCCUPANCIES ONLY LIMITS: $ Limit any one accident, is the Property General limit of Coverage per Occurrence or $60,000,000 whichever is less any one accident $ 5,000,000 Business Income and Extra Expense $ 100,000 Service Interruption $ 100,000 Perishable Goods t u �y�-L O $ 100,000 Data Restoration $ 100,000 Demolition and Increased Cost of Construe —rh i S C vU -e-✓'z.. -C- $ 100,000 Expediting Expenses • $ 100,000 Pollutants $ 100,000 CFC Refrigerants $ 50,000 Ice Buried Piping 1• Does t he a pp licant currently have Boiler& Machinery coverage? Yes N.No 2. Name of current Boiler& Machinery carrier Expiration Date: 3. Has the applicant had any boiler and machinery breakdowns in the past 3 years? J'Yes c No &pla ci C If yes, please provide description and amount. (u r'ne�ctic i )",/</e-e Pe.r/<— /1-t w - 7oZ�g 76 ��c r`✓lu cti i`, ea .— $'13L .OD L2003) •4. Desired Deductible: LMCITAPP.EQUIPBRKDWN(11/03) Page 1 of 2 * LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 5. REFERRAL OCCUPANCIES(Limited Coverage) Important: If the applicant has any of the following exposures,further analysis may be required by LMCIT. Coverage for any of these exposures cannot be bound unless approved by LMCIT. Each exposure must indicate a yes or no response. Special conditions, endorsements, limits and deductibles may apply. Please contact your LMCIT underwriter. A. Refuse burning facility(HBB) ❑Yes [ No B. Equipment for recovering methane or other gases from a sewage treatment plant or landfill, or any other system for producing industrial gases (HBG) ❑ Yes KNo C. Hospital/Clinic equipment listed below(HBH) ❑ Yes ISkyNo 1. CT Scanner ❑Yes ❑ No 2. MRI Unit ❑ Yes ❑ No 3. PET ❑ Yes ❑ No 4. Linear Accelerator ❑Yes ❑ No 5. Lithotripter ❑ Yes ❑ No D. Steam or hot water district heating system (HBM) ❑ Yes N'No E. Electrical Generating Equipment Yes ❑ No Type: %Diesel (HBD) ❑ Other(HBE), describe This does not include emergency back-up generators that serve only a single building or function and are not part of a municipal utility. Special Note: LMCIT can provide equipment breakdown coverage for diesel generating equipment, but not for other types of electrical generation equipment such as steam or gas turbines,wind turbines, or hydro-electric facilities. If the utility has both diesel and other types of equipment,the entire risk must be _ placed with an equipment breakdown insurance company. LMCITAPP.EQUIPBRKDWN(11/03) Page 2 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST EXCESS LIABILITY APPLICATION 0 A pp licant: e417/ r Oa- o k- T 6 V Date: 6 // woq Limit ofcess coverage desired: { $1,000,000 ❑ $2,000,000 El $3,000,000 El $4,000,000 ❑ $5,000,000 Do you want t e Excess to apply to the Uninsured and Underinsured coverage provided by the primary covenant? Yes El No If yes, the automobile UM/UIM limits must be$1,000,000. The Excess Covenant does not automatically apply to liquor li 'lity. Do you want the excess to apply to liquor liability? ❑ Yes No Special Note: The liquor liability primary limits must be$1,000,000. Employers Liability: Carrier: LM CI_ T. 1 Limits: 1 1 00 010M Policy Number: I" , &L- "-'4'O Policy Period: -71-710 _ -7/-7 /09— Does applicant now have or contemplate any exposure under: (If yes, attach sheet with payroll figures.) • (a) Jones Act or Admiralty Jurisdiction ❑ Yes /ki kiNo No (b) Federal Railroad Employees Act ❑ Yes (c) Federal Longshoremen's & Harbor Workers Act ❑ Yes 'No To what extent does applicant have primary insurance to cover these exposures? it(a____) IF THIS IS A RENEWAL, PLEASE INDICATE IF RENEWAL IS TO BE BOUND: RYES ❑ NO Note: Coverage is excess of LMCIT coverages only. Some of the coverage is not follow form. i • LMCITAPP.12(11/97)(Rev. 11/03) Page 1 of 1 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST SUBMITTED BY: L1 (& IC( , .ry eS PRODUCER: ,1�� ADDRESS: IV.-- SaerfA 1 OI SF L Z j p!/ - APPLICATION FOR OPEN MEETING LAW DEFENSE COST REIMBURSEMENT AGREEMENT APPLICANT'S INSTRUCTIONS: 1. Please answer all questions. If the answer is NONE, please state NONE. 2. If space is insufficient to provide a complete response, attach a separate sheet. of 3. The application must be signed by an authorized representative o the City. Special Note: Please answer all questions. These questions are intended to provide general information only. The information provided will also be used for a proactive loss control procedure if needed. APPLICANT 1. Name of cityf, r other p lic ffitity whos ity officials are to be ov red under the Agreement. ei 0(21- 7461 2. Principal Address: Me V 01112117NIMBELINU 3. If Joint Powers entity, identify participants: c 41) LMCITAPP.OML(11/97)(Rev.11/03) Page 1 of 3 • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST CLAIM HISTORY • List incidents of threatened or actual open meeting law litigation involving city related individuals in the last five years. For each incident give its approximate date and its resolution, including the penalty imposed, if any, and the amount of attorneys fees incurred in defending the incident. '7`G' wr94 1"n �G. "�' � "R'. —,,,� �r+'ihp"q��" r p,. a re, e�^^ €^ �A6Lu^o o t � PX 'S ,c � �T � P x4 ft n 4 rc �' i .J ti:I i • 7 i 1 pp � V .,y {� ,. i a �°' �f!!3 ? � ? tg S� �Y t` 5 3 1 tt t { fl j n q �� t k ,�} y'�t�y'y�y E I � i✓ f ; 5 '-7l `1 f .5� r 1: �` t ��` 8 �P 3J l:1a S- 1 , �' r _�. c • 2. Are you presently aware of any other incidents or situations which (aNO y result in an open meeting law claim or litigation against city related individuals? 1:1 YES [ If YES, give details: 3. What action has been taken to prevent future incidents or claims? • LMCITAPP.OML(11/97)(Rev.11/03) Page 2 of 3 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST OPEN MEETING LAW II QUESTIONNAIRE 1. Description of orientations and/or training provided for all elected officials (GTS programs, League programs, Handbook for Minnesota Cities, loss control seminars ...)on the subject of the open meeting law: wh-e_ a, l&G,--y-ar 2. Have all new members attended the League Conference for Newly Elected Officials? YES ❑ NO 3. Do all officials understand the Open Meeting Law and the Cities'compliance procedures? YES ❑ NO 4. Description of method of documenting/official meetings (written, audio, video, ...): 411 5. Does legal council attend all official meetings? YES ❑ NO If no, describe service relationship with city attorney. 6. Is education provided for the elected officials in the proper policy and procedures? a) Land use decision making: YES El NO b) Employment practices: YES ❑ NO 7. Please indicate the percentage of reimbursement of defense costs. C:180% 00% • BY: /ii I /I / ` ' /S-tr or- -, (Signature =nd tie of Authorized -epresentative) LMCITAPP.OML(11/97)(Rev.11/03) Page 3 of 3 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • SUBMITTED BY: PRODUCER: ADDRESS: ZIP: APPLICATION FOR MINNESOTA PETROFUND SUPPLEMENTAL REIMBURSEMENT AGREEMENT APPLICANTS INSTRUCTIONS: 1. Answer all questions. If the answer is NONE, please state NONE. 2. If space is insufficient to provide a complete response, attach a separate sheet. • 3. The application must be signed and dated by an authorized representative of the City. 4. PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION. APPLICANT 1. Name of City or other public entities to be covered under the Agreement. LMCITAPP.MPRAAP(11/97)(Rev. 11/03) Page 1 of 6 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 2. Principal Address: • 3. If Joint Powers entity, identify participants: 4. Designate the public official primarily responsible for environmental protection: NAME: TITLE ADDRESS: TELEPHONE • TANK SITE INFORMATION 1. Please list and describe all active and inactive underground and above ground storage tanks on the attached storage tank schedule. This list must include all tanks acquired through the Housing and Redevelopment Authority and the Economic Development Authority or any similar department/agency. 2. Are all tanks registered with the Minnesota Pollution Control Agency? El YES ❑ NO If NO, please explain below: LMCITAPP.MPRAAP(11/97)(Rev. 11/03) Page 2 of 6 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 3. Do all tanks including piping meet all local storage tank regulations? ❑YES ❑ NO i If NO, please explain below: 4. Do all tanks including piping meet all state storage tank regulations? El YES ❑ NO If NO, please explain below: • 5. Do all tanks including piping meet all Federal storage tank regulations? ❑ YES ❑ NO If NO, please explain below: 6. Have you received any complaint or notice that any of your tanks including piping are leaking or have you any other indication that any of your tanks including piping are leaking? ❑ YES ONO If YES, please explain below: • LMCITAPP.MPRAAP(11/97)(Rev. 11/03) Page 3 of-6 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST CLAIM HISTORY • 1. List individual petroleum tank release incidents or claims and damages/expenses: Describe Injury Amounts Paid Date of Incident or Damage or Reserved Location 2. Identify your tank sites that have been the subject of environmental litigation, claim or administrative prosecution or complaint. Please give details: • 3. Are you aware of any other incidents or conditions which may result in a claim against you? ❑ YES ❑ NO If YES, give details: 4. Have you ever performed any remedial clean-up actions at any of your tank sites? ❑ YES ❑ NO If YES, give details: • LMCITAPP.MPRAAP(11/97)(Rev. 11/03) Page 4 of 6 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • The undersigned authorized representatives of the Applicant represents to the best of his/her knowledge the statements herein are true, and it is agreed that this application shall become incorporated as a part of the Minnesota Petrofund Supplemental Reimbursement Agreement if accepted by LMCIT. LMCIT is hereby authorized to make any investigation and inquiry in connection with this application, as it deems necessary. Dated at this day of ,20.. (Name of Applicant) BY: (Signature and Title of Authorized Representative) 110 • LMCITAPP.MPRAAP(11/97)(Rev. 11/03) Page 5 of 6 • • I 9 L ). V c I O 7 O O• � JD Q m CO C 0 U 7 L c O U 0 a) I- 1-N I- W c F ■o C.) 0 0 Z a) J Q a Ui D Z w I C6 U y U.1 N c 1 '� Y rta) o IF a V I— 1 0 IV N 0 W Z Lr C Z_ o g N g LL 'c C U Q 0 ° w -o o Y C O 1 Ch t9 a F Ill _ J M O r-. _N ~ > n N• 0 ID U I as QW I 0° E tq ca H • o° U U CO O• < --I O LEAGUE OF MINNESOTA CITIES INSURANCE TRUST LIQUOR LIABILITY APPLICATION • -APPLICANT: AGENTS NAME: TELEPHONE NUMBER 1. Effective Date: Name of Licensee: License# 2. Limits of Liability:$ Per Claim $ Annual Aggregate 3. Receipts: Alcoholic Beverages$ (Past 12 months) $ (Estimated next 12 months) 4. List of locations covered and their operations: Location: Operation: Location: Operation: 5. Underwriting: (A) Has the applicant or any employee,officer or licensee incurred any claim for liquor liability in the past 5 • years? ❑Yes ❑ No If yes,explain: Is the applicant aware of any incidents which may lead to a claim? ❑Yes ❑ No If yes,explain: (B) Have there been any fights or assaults inside or outside the locations among patrons in the past year? ❑Yes ❑ No If yes,give details: Have there been any incidents of any employee,officer,or licensee using reasonable force to remove patrons? ❑Yes ❑ No If yes, explain: (C) Does the applicant provide for their employees to receive formal training in the following areas? Operations? ❑Yes ❑ No Handling of minors? ❑Yes ❑ No Handling of intoxicated customers? ❑Yes ❑ No How often is the training done? By whom? Does the applicant provide any additional training? ❑Yes ❑ NO If yes,explain: • LMCITAPP.LLC(11/97)(Rev. 11/03) Page 1 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST (D) Has the applicant,or any owner, partner,officer,member of licensee ever had a license revoked, • refused,or suspended? 0 Yes ❑ No If yes,give details: (E) Previous Carrier: Exp. Date: Premium Policy Number: Limit of Liability (F) Years in business at this location under current ownership: If under 2 years,give previous experience: (G) Has applicant or employee ever been fined or cited for violations of a law or ordinance relating to sales of alcohol?(After hours, minor, etc.) ❑Yes ❑ No If yes, explain: (H) Normal Open/Closing hours: Mon-Thurs Fri Sat Sun (I) Does applicant have entertainment? ❑Yes- ❑ No If yes;explain: (J) What is the turnover of bartenders? (K) Is there a documentation procedure in place for incidents? ❑Yes ❑ NO If yes,explain: 6. Do you have any special events sponsored and controlled by the liquor store? ❑Yes ❑ NO If yes, please describe: Coverage is excluded. An endorsement is necessary. Please let us know if you want coverage. 7. Do you have any other special events that is not sponsored or controlled by the liquor store? If yes, explain: - Coverage is excluded. An endorsement is necessary. Please let us know if you want coverage. 8. Receipts On-Sale Receipts Off-Sale Receipts Special Events Number of Days • By: (Signature and Title of Authorized Representative) LMCITAPP.LLC(11/97)(Rev. 11/03) Page 2 of 2 k LEAGUE OF MINNESOTA CITIES INSURANCE TRUST NO FAULT SEWER BACK-UP COVERAGE APPLICATION 411 APPLICANT: AGENTS NAME: TELEPHONE NUMBER 1. Inspection and maintenance program Does the applicant have an inspection and maintenance program? ❑Yes❑ No Please describe briefly or attach a copy of the program. 2. Problem area identification procedures Does the applicant have in place procedures for identifying and abating problem areas in the system that may require more frequent inspection or cleaning? ❑Yes❑ No Please describe briefly. • 3. Emergency response system Does the applicant have a procedure for providing 24-hour/7 day emergency response to sewer back-ups? ❑Yes❑ No Please describe briefly. 4. Inflow and Infiltration Procedures(Storm water getting into the sanitary sewer system) Does the applicant have an active plan to minimize the effect of storm water getting into the sanitary sewer system? ❑Yes❑ No Please describe briefly. • LMCITAPP.SEWERBU(11/00)(Rev. 11/03) Page 1 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 5. Documentation Does the applicant maintain written records of its normal maintenance and inspections of the sewer system? ❑Yes❑ No Does the applicant maintain written records for its cleaning and inspection of problem sewer lines? ❑Yes❑ No 6. Planning Does the applicant have capital improvements planning in place to remedy any ongoing problems with its sewer system? ❑Yes ❑ No Please provide details including a description of the plan,availability of financial resources and timetables. Special Note: No fault Sewer Back-up Coverage cannot be bound until the applicant has met the underwriting criteria and has passed a No Fault Sewer Back-up Resolution. By: (Signature and Title of Authorized Representative) • LMCITAPP.SEWERBU(11/00)(Rev. 11/03) Page 2 of 2 Julie Hultman From: Judy Hoist nt: Wednesday, June 23, 2004 8:15 AM Julie Hultman Subject: Insurance Info Julie, I'm completing the paperwork for the City insurance and there are a few things I will need for you. 1. Number of building permits for 2003 (04(p 2. Number of Variances granted for 2003 ._ '3 3. Number of Variances denied for 2003 O 4. Number of CUPs granted for 2003 5 ( (( C_nswi .2 cl 5. Number of CUPs denied for 2003 — ( • vV 6-4aLLY1 Q.J. 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H W dJ H Z H Z w w 0 cn 43 03 H 0 in Z Z 124 0 0 CO RI H in H E H H H a H 0 I H H 0 H 0 g zn H Z 0 in x x Z 0 H I PG U A a A H H z 67 E U 0 W W O O I O "Z. 7-. 7. x H S in 3 H H O H H H • 't H �7 H W W W r.� I I >+ H O a H H H O a s a2 t>a Val a� I-7 U H a m a m 0) 0 N H H W N N d) IY,. H H H H H H H W Cn �, H 4) El H a a P4 1 a W W W O x H a E -r�7i w w w w w 0 0 a C) CO F1 •g-1 .r 1 x E E E E W ti) W H W H -ri .,44 .r4 al P. 1a )m U CJ U U U x in cn z F 14 0 U 0 Gl N C) G) 0) a a a P. a I,I ` • er b P ri co O d 0 O W E N 0 01 to Id o 0 0) ld .11 H Ul A N 0 ri 0 a .0 U 0 0 0 > d • 0 li 14 14 o U a 11 J • b C2 0 a League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 Phone (651)215-4173 Information Page 1. The "City" RENEWAL Agreement No.: 0200072918 OAK PARK HEIGHTS, CITY OF PO BOX 2007 "City" is: x City OAK PARK HEIGHTS MN 55082 _ Joint Powers Entity Other(describe) 2. The Agreement Period is from 12:01 a.m. 7/07/2004 to 12.01 a.m. 7/07/2005 at the "City's" address. 3. A. Workers' Compensation Coverage: Part One of the Agreement applies to the Workers' Compensation Law of any state of the United States of America and the District of Columbia. B. Employers Liability Coverage: Part Two of the Agreement applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury-Each Occurrence $1,000,000 Bodily Injury by Disease-Agreement Limit $1,000,000 C. Part Three of the Agreement applies to Infectious Disease Diagnostic Testing. D. Part Four of the Agreement applies to Peace Officers' Posttraumatic Stress Syndrome Benefit. E. This Agreement includes these amendments and schedules: • 4. Retro-rating option selected? _Yes x No 5. Elected Officials Covered? Yes Boards and Commissions Covered (List) NONE 6. The premium for this Agreement will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rates Entries in this item,except as specifically provided Estimated Estimated Total Per$100 of Code elsewhere in this Agreement; Do not modify any of the Annual Annual Remuneration No. other provisions of the Agreement Premium Remuneration SEE ATTACHED SCHEDULE FOR DETAILS Manual Premium 32886. Experience Modification .83 5591. Standard Premium 27295. Managed Care Credit 0% Deductible Credit .0 % Agent: 411709883 503.54 Premium Discount 2118. 0. FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS Net Deposit Premium 25177. 232 S LAKE ST FOREST LAKE MN 55025- 7/23/2004 LM 4670(12/99) League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 (651)215-4173 Ike"City" Agreement No.: 0200072918 Agreement Period From: 7/07/2004 OAK PARK HEIGHTS, CITY OF To: 7/07/2005 PO BOX 2007 OAK PARK HEIGHTS MN 55082 CONTINUATION SCHEDULE FOR INFORMATION PAGE REMUNERATION RATE CODE DESCRIPTION EST. PREM 13870. 6.27 5506 STREET CONSTRUCTION 870. 86689. 2.70 7520 WATERWORKS 2341. 52014. 3.59 7580 SEWAGE DISPOSAL PLANT 1867. 678375. 3.61 7720 POLICE 24489. 349018. .54 8810 CLERICAL OFFICE EMPLOYEES NOC 1885. 11372. 2.26 9016 SKATING RINK OPERATION 257. 12136. 2.86 9102 PARKS 347. 74900. .98 9410 MUNICIPAL EMPLOYEES 734. 26000. .37 9411 ELECTED OR APPOINTED OFFICIALS 96. Manual Premium 32886. Agent: 411709883 00874 : FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST FOREST LAKE MN 55025- 7/23/2004 LM 4680(8/99) 44p • League of Minnesota Cities • Insurance Trust LMC 145 University Avenue West St. Paul, MN 55103-2044 (651) 215-4173 League of Minnesota Cities Fax: (651) 281-1297 Cities promoting excellence Workers' Compensation and Employers' Liability IMPORTANT 110 Report all workers' compensation injuries to the office of: League of Minnesota Cities Insurance Trust 145 University Avenue West, St. Paul,MN 55103-2044 Phone (651) 215-4173 Fax 888-234-7839 . In the Twin Cities 651-215-4185 For assistance on Fax First call 651-215-4169 If an employee is injured: (1) Assist in obtaining medical attention if necessary. (2) Notify the office listed above. **IMPORTANT** PLEASE READ YOUR AGREEMENT • LM 4660(12/03) * • .v. its In consideration of the deposit of the premium with the League of Minnesota Cities Insurance Trust(herein LMCIT)and in reliance upon the statements in the Information Page,and subject to all terms of this agreement and the LMCIT trust document,LMCIT, acting on behalf of its members,pursuant to their obligations,all acting through Berkley Risk Administrators Company,LLC,which is the Administrator named in the Information Page made a part hereof,agrees with you,the City,named in the Information Page as follows: • GENERAL SECTION A. The Agreement contractors;or a relief association and its officers,employees and members. This agreement includes at its effective date the Information Page and all amendments and schedules listed there. It is an agreement C. Workers' Compensation Law of participation between you(the employer named in item 1 of the Information Page) and us (LMCIT). The only agreements Workers'Compensation Law means the workers'compensation relating to this plan are stated in this agreement and the LMCIT law and occupational disease law of the States named in item 3.A Trust document. The terms of this agreement may not be of the Information Page. It includes any amendments to that law changed or waived except by amendment issued by us to be part which are in effect during the period of this agreement. It does of this agreement. not include the provisions of any law that provides non-occupational disability benefits. B. Who is Covered D. Locations You are covered if you are the "City" named in item 1 of the Information Page. "City"means the city or other governmental This agreement covers all of your workplaces listed in items 1 or body,political subdivision,board or department or entity named 5 of the Information Page; and it covers all other workplaces in in the Information Page. Unless specifically named in the any state unless you have other insurance for such workplaces. Information Page, "City" shall not include a gas, electrical or steam utilities commission; port authority, housing and E. Incidental Coverages redevelopment authority, or similar agency, board or commission; hospital or nursing home board or commission; 1. Part One of this agreement applies to work performed by you welfare or public relief agency; school board; or joint powers subject to the Longshoremen's and Harborworkers'A board. 2. Part Two of this agreement applies to work performed by For purposes of Part Two-Employers'Liability Coverage and for you subject to the Federal Employer's Liability Act. purposes of damages sought against them under Section 176.82 of the Minnesota workers' compensation law,the following are 3. Part Two of this Agreement applies to work performed by additional covered parties for actions performed within the scope you subject to the Jones Act or U.S.Maritime Law. of their duties: A member of the city council;a member of any board or commission of the city that is named in the Information This paragraph does not apply to bodily injury covered under any Page;an elected or appointed official of the city;an employee of other policy, agreement or plan issued to you. It does not apply the city;a volunteer person or organization while acting on behalf even if the other policy, agreement or plan does not apply of the city;any other authorized person or agent of the city while because of an other insurance clause,deductible or limitation of acting on behalf of the city, but excluding independent liability clause,or any similar clause. PART ONE -WORKERS' COMPENSATION COVERAGE A. How This Coverage Applies last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the period of this This workers'compensation coverage applies to bodily injury or agreement. death by accident or by disease, provided the following conditions are met: B. We Will Pay 1. Bodily injury by accident must occur during the period of We will pay promptly from the assets of LMCIT,when due,the this agreement. benefits required of you by the workers' compensation law. 2. Bodily injury by disease must be caused or aggravated by the • conditions of your employment. The employee's last day of LM 4660(12/03) Page 1 of 8 A. C. We Will Defend provided by the workers'compensation law on your behalf,you will reimburse us promptly. We have the right and duty to defend, at LMCIT expense, any claim,proceeding or suit against you and any other covered party G. Recovery From Others lf nefits payable under this agreement. We have the right to in tigate and settle these claims,proceedings or suits. I. We have your rights,and the rights of persons entitled to the We have no duty to defend a claim,proceeding or suit that is not benefits of this agreement, to recover our payments from covered by this agreement. anyone liable for this injury. You will do everything necessary to protect those rights for us and to help us enforce D. We Will Also Pay them. We will also pay from the assets of LMCIT these costs, in 2. You authorize us to pursue and settle on your behalf any addition to other amounts payable under this agreement as part of increased premium claim to which you may be entitled to any claim,proceeding or suit we defend: under Minn. Stat. Section 175.061 subd.5(b). 1. Reasonable expenses incurred at our request,but not loss of 3. You will receive 10%of the "net recovery", not to exceed earnings; 50% of your premium for the most current year. We will retain the remainder and apply it to reduce the incurred cost 2. Premiums for bonds to release attachments and for appeal of the claim for purposes of calculating your experience bonds in bond amounts up to the amounts payable under this modification. For purposes of this section, "net recovery" agreement; means the total we recover on claims pursuant to paragraphs I and 2,minus any legal expenses or other costs of recovery. 3. Litigation costs taxed to you; H. Statutory Provisions 4. Interest on a judgment as required by law until we offer the amount due under this agreement;and These statements apply where they are required by law. 5. Expenses we incur. 1. As between an injured worker and us,we have notice of the injury when you have notice. E. er Insurance 2. Your default or your bankruptcy or insolvency will not We will not pay more than our share of benefits and costs relieve us of our duties under this agreement after an injury covered by this agreement and another insurance policy or occurs. self-insurance plan. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any 3. We are directly and primarily liable to any person entitled to insurance policy or self-insurance plan is exhausted,the shares of benefits payable under this agreement. Those persons may all remaining insurance policies or self-insurance plans will be enforce our duties; so may an agency authorized by law. equal until the loss is paid. Enforcement may be against us or against you and us. F. Payments You Must Make 4. Jurisdiction over you is jurisdiction over us for purposes of the workers'compensation law. We are bound by decisions You are responsible for any payments in excess of the benefits against you under the law, subject to the provisions of this regularly provided by the workers' compensation law including agreement that are not in conflict with that law. those required because: 5. This coverage conforms to the parts of the workers' 1. Of your serious and willful misconduct; compensation law that apply to: 2. You knowingly employ an employee in violation of law; a. Benefits payable by this agreement;or 3. You fail to comply with a health or safety law or regulation; b. Special taxes, payments into security or other special or funds, and assessments payable by us under that law. 4. You fail to comply with the reporting requirements of the 6. Terms of this agreement that conflict with the workers' Workers' Compensation Law, causing late payment of compensation law are changed by this statement to conform efits to your employee and resulting in assessment of to that law. lties. Nothing in these paragraphs relieves you of your duties under this If we make any payments in excess of the benefits regularly agreement. LM 4660 (12/03) Page 2 of 8 / • i PART TWO-EMPLOYERS' LIABILITY COVERAGE A. How This Coverage Applies 1. Liability assumed under a contract,except that this exclusion This employers' liability coverage applies to bodily injury or does not apply to a warranty that your work will be done death by accident or by disease, provided the following workmanlike manner; conditions are met: 2. Punitive or exemplary damages because of bodily injury to 1. The bodily injury must arise out of and in the course of the an employee employed in violation of law; injured employee's employment by you. 3. Bodily injury to an employee while employed in violation of 2. The employment must be necessary or incidental to your law with your actual knowledge or the actual knowledge of work. any of your executive officers; 3. Bodily injury by accident must occur during the period of 4. Any obligation imposed by a workers' compensation, this agreement. occupational disease, unemployment compensation, or disability benefits law, or any similar law; 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of 5. Bodily injury intentionally caused or aggravated by you; exposure to the conditions causing or aggravating such bodily injury by disease must occur during the period of this 6. Bodily injury occurring outside the United States of agreement. America, its territories or possessions, and Canada, except that this exclusion does not apply to bodily injury to a citizen 5. If you are sued,the original suit and any related legal actions or resident of the United States of America or Canada who is for damages for bodily injury by accident or by disease must temporarily outside these countries;or be brought in the United States of America,its territories or possessions,or Canada. 7. Damages arising out of the discharge of, coercion of, or discrimination against any employee in violation of law. B. We Will Pay D. We Will Defend We will pay from the assets of LMCIT all sums you legally must pay as damages because of bodily injury to your employees, We have the right and duty to defend, at LMCIT expense, any provided the bodily injury is covered by this Employers'Liability claim,proceeding or suit against you for damages payable under coverage. this agreement. We have the right to investigate and settle these claims, proceedings and suits. We have no duty to defend a The damages we will pay, where recovery is permitted by law, claim, proceeding or suit that is not covered by this agreement. include damages: We have no duty to defend or continue defending after we have paid our applicable limit of liability under this agreement. 1. For which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages E. We Will Also Pay claimed against such third party as a result of injury to your employee; We will also pay these costs, in addition to other amounts payable under this agreement as part of any claim,proceeding,or 2. For care and loss of services; suit we defend: 3. For consequential bodily injury to a spouse, child, parent, 1. Reasonable expenses incurred at our request;but not loss of brother or sister of the injured employee; provided those earnings; damages are the direct consequences of bodily injury that arises out of and in course of the injured employee's 2. Premiums for bonds to release attachments and for appeal employment by you; and bonds in bond amounts up to the limit of our liability under this agreement; 4. Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a 3. Litigation costs taxed against you; capacity other than as an employer. 4. Interest on a judgment as required by law until we offer the C. Exclusions amount due under this agreement;and This agreement does not cover: 5. Expenses we incur. LM 4660(12/03) Page 3 of 8 r ' I, 2. Bodily Injury by Disease - Agreement Limit. The limit F, Other Insurance shown for"Bodily Injury by Disease-Agreement Limit"is the most we will pay for all damages covered by this If an claim against you is also covered by another insurance agreement and arising out of bodily injury by sustain bodily p or self-insurance plan, we will pay only for our injury by disease,and regardless of the number of claimants. pr rtionate share of the loss. Our proportionate share will be Bodily injury by disease does not include disease that results determined by applying the ratio that the limit of liability directly from a bodily injury by accident. provided by this agreement bears to the total of all limits of liability provided by all policies or plans in effect to the total 3. We will not pay any claims for damages after we have paid amount payable for the loss. The limits of liability and amount the applicable limit of our liability under this agreement. payable under this agreement and any other policy or plan shall be calculated as if each plan or policy were the only one H. Recovery From Others applicable.The limits of liability and amount payable under any other policy or self-insurance plan in effect shall be included in We have your rights to recover our payment from anyone liable the calculation,regardless of whether it is described as primary, for any injury covered by this agreement. You will do everything excess,contributory,contingent,or otherwise,unless that policy necessary to protect those rights for us and to help us enforce or plan is specifically described as providing coverage in excess them. of the limits of this agreement. I. Actions Against Us G. Limits of Liability There will be no right of action against us under this agreement Our liability to pay for damages is limited. Our limits of liability unless: are shown in item 3.B. of the Information Page. They apply as explained below: 1. You have complied with all the terms of this agreement;and 1. Bodily Injury - Each Occurrence. The limit shown for 2. The amount you owe has been determined with our consent "Bodily Injury-Each Occurrence" is the most we will pay or by actual trial and final judgment. for all damages covered by this agreement because of bodily injury by accident or disease to one or more employees in This agreement does not give anyone the right to add us as a erone accident,regardless of the number of claimants. defendant in an action against you to determine your liability. PART THREE-INFECTIOUS DISEASE DIAGNOSTIC TESTING A. We Will Pay 1. Exposure Incident means a specific eye, mouth, or other Subject to the conditions listed below, LMCIT agrees to pay mucous membrane,non-intact skin or parenteral contact with from its assets the usual and customary costs and expenses for blood or other potentially infectious materials that result from the performance of an employee's duties. 1. Diagnostic testing of your employees who have had an Exposure Incident that could result in an Infectious Disease; 2. Infectious Disease means any form of viral or infectious and hepatitis, human immunodeficiency virus (HIV), acquired immunodeficiency syndrome(AIDS),tuberculosis(TB),or 2. Diagnostic testing of the person or persons who were the Bacillus anthracis(anthrax). source of the blood or other potentially infectious materials when an employee has had an Exposure Incident. C. Limits and Conditions B. Definitions LMCIT's responsibility to pay costs and expenses for diagnostic testing is limited and conditioned as follows: For purposes of this Coverage Part, the following definitions apply: 1. The Exposure Incident must occur during the term of this agreement. • LM 4660 (12/03) Page 4 of 8 I • 2. The most LMCIT will pay for diagnostic testing associated 4. In accordance with the provisions of Minn. Stat. Sec. with an Exposure Incident to any one employee is$2,500. 176.221 subd. 1, payment for diagnostic testing as described in this agreement is not an admission that an employee's 3. An Exposure Incident does not alone constitute a Personal contraction of an Infectious Disease constitutes a Injury as that term is defined under Minnesota Workers' compensable Occupational Disease under Minn Compensation law. Accordingly,absent actual contraction Workers' Compensation law; and it does not consti of an Infectious Disease, payment for diagnostic testing waiver of the city's or LMCIT's right to contest the issue of subsequent to an Exposure Incident is not required under whether an employee's contraction of an Infectious Disease Minnesota Workers' Compensation Law. Rather,payment constitutes a compensable Occupational Disease under for diagnostic testing as described in this endorsement is Minnesota Workers'Compensation law. made independent of the city's obligations, if any, under Minnesota Workers' Compensation Law and is intended to 5. LMCIT reserves the right to discontinue payment of costs meet the city's obligation under Federal OSHA law to and expenses for diagnostic testing if in its opinion further provide at no cost to the employee,medical evaluations and diagnostic testing is no longer medically appropriate under treatment after an Exposure Incident. the particular circumstances of the Exposure Incident. PART FOUR- PEACE OFFICERS' POSTTRAUMATIC STRESS SYNDROME BENEFIT A. Intent and Purpose C. Conditions and Limitations The purpose of Part Four is to assist the city in providing the LMCIT will not pay or reimburse any benefits which have been benefits required by law for peace officers suffering from paid or reimbursed by any of the following: posttraumatic stress syndrome as a result of lawful use of force resulting in taking of life or great bodily harm. The benefits 1. Workers compensation; provided by Part Four are intended to supplement,rather than to replace, benefits provided by any other source. 2. The city's employee health benefit plan; B.We Will Pay 3. Any disability insurance policy;or • Subject to the conditions and limitations listed below, LMCIT 4. PERA or any other retirement plan. will reimburse the city for any benefits which the city is required to provide to a peace officer pursuant to Minnesota Statutes LMCIT will not reimburse any health benefit plan or carrier or Section 299A.411. any disability insurance carrier for any benefits provided by that plan or carrier. PART FIVE -YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this 4. Cooperate with us and assist us, as we may request, in the agreement. Your other duties are listed here: investigation,settlement or defense of any claim,proceeding or suit. 1. Provide for immediate medical and other services required by the workers' compensation law. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may 6. Do not voluntarily make payments, assume obligations or need. incur expenses,except at your own cost. This particular duty does not apply to Part 4 — Peace Officers' Posttraumatic 3. Promptly give us all notices, demands, and legal papers Stress Syndrome Benefits. related to the injury, claim,proceeding or suit. • LM 4660 (12/03) Page 5 of 8 i PART SIX—PREMIUM A. Our Manuals than the highest minimum premium for the classifications covered by this agreement. If this agreement is canceled, final emiums for this agreement will be determined by our premium will be determined in the following way unless our m uals of rules,rates,rating plans and classifications. We may manuals provide otherwise. change our manuals apply changes and a the ch es to this a Bement. PP Y g �' 1. If we cancel,final premium will be calculated pro rata based B. Classifications on the time this agreement was in force. Final premium will not be less than the pro rata share of the minimum premium. Item 5 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications 2. If you cancel, final premium will be more than pro rata. It were assigned based on an estimate of the exposures you would will be based on the time this agreement was in force, and have during the period of this agreement. If your actual increased by our short rate cancellation table and procedure. exposures are not properly described by those classifications,we Final premium will not be less than the minimum premium. will assign proper classifications, rates and premium basis by amendment to this agreement. F. Records C. Remuneration You will keep records of information needed to compute premium. You will provide us with copies of those records when Premium for each work classification is determined by we ask for them. multiplying a rate times a premium basis. Remuneration is the most common premium basis. This premium basis includes G. Audits and adjustments payroll and all other remuneration paid or payable during the period of this agreement for the services of: You will let us examine and audit all your records that relate to this agreement. These records include ledgers,journals,registers, 1. All your officers and employees engaged in work covered by vouchers, contracts, tax reports, payroll and disbursement this agreement;and records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the 2.011 other persons engaged in work that could make us liable period of this agreement and within three years after this der Part One(Workers' Compensation Coverage)of this agreement ends. Information developed by audit will be used to agreement. If you do not have payroll records for these determine final premium. Except for premium adjustments persons, the contract price for their services and materials pursuant to a retro-rating plan,no premium adjustments will be may be used as the premium basis. This paragraph 2 will not made for any coverage period after one year following apply if you give us proof that the employers of these completion of the audit for that coverage period. persons have lawfully secured their workers' compensation obligations. D. Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers' compensation law is not valid. E. Final Premium The premium shown on the Information Page, schedules, and amendments is an estimate. The final premium will be determined after this agreement ends by using the actual,not the estimated,premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this agreement. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less • LM 4660 (12/03) Page 6 of 8 I PART SEVEN-CONDITIONS A. Duty Indemnify to Y D. Long Term Agreement Our duty to pay on behalf of or to indemnify a covered party other than the"city"shall not apply to any act,error or omission: If the period of this agreement is longer than one year and sill) days,all provisions of this agreement will apply as though a new 1. Which constitutes malfeasance in office; or agreement were issued on each annual anniversary that this agreement is in force. 2. Which constitutes willful neglect or duty;or E. Transfer of Your Rights and Duties 3. Which constitutes bad faith; or Your rights or duties under this agreement may not be transferred 4. For which the "city" is not authorized to indemnify any without our written consent. person by statute;or F. Cancellation 5. Which constitutes dishonesty on the part of a covered party; or 1. You may cancel this agreement. You must mail or deliver advance written notice to us stating when the cancellation is 6. Which constitutes the willful violation of a statute or to take effect. ordinance by any official,employee or agent of the "city". 2. We may cancel this agreement. We must mail or deliver to The terms "malfeasance", "willful neglect of duty", and "bad you written notice of cancellation at least: faith"shall be given the same meaning in this agreement as given in the applicable statute with respect to the"city's"duty to defend a. thirty days before the effective date of cancellation if or indemnify its officials,employees or agents. LMCIT cancels for nonpayment of premiums; or B. No Waiver of Statutory Liability Limitations or b. sixty days before the effective date of cancellation if Immunities. LMCIT cancels for any other reason. 1. It is the express intent of the city and of LMCIT that the Mailing the notice to you at your mailing address shol, procurement of this agreement shall not waive any monetary item 1 of the Information Page will be sufficient to prove limits of liability provided by Minnesota Statute 466.04,by notice. any comparable or successor statute, or by common law, which may be applicable to the "City" or to any other 3. The period of this agreement will end on the day and hour covered party;and that any previous waiver of liability limits stated in the cancellation notice. is revoked to the extent that it may apply to claims covered under this agreement. 4. Any of these provisions that conflicts with a law that controls the cancellation of the coverage in this agreement is changed 2. It is the express intent of the "City" and of LMCIT that the by this statement to comply with that law. procurement of this agreement shall not waive any other immunities,limitations,or defenses imposed by or available G. Accessibility under any statute or common law which is applicable to the "City"or to any other covered party. All "cities" that participate in this program are jointly and severally liable for all claims and expenses of the program. The C. Inspection amount of any liabilities in excess of assets may be assessed to the participants when a deficiency is identified. We have the right,but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They H. Sole Representative relate only to coverage and the premiums to be charged. We may also recommend changes. While they may help reduce losses,we The City first named in item 1 of the Information Page will act on do not undertake to perform the duty of any person to provide for behalf of all covered entities to change this agreement,received the health or safety of your employees or the public. We do not return premium, and give or receive notice of cancellation. warrant that your workplaces are safe or healthful or that they comply with laws,regulations,codes or standards. •. LM 4660 (12/03) Page 7 of 8 ' i dN WITNESS WHEREOF,the City agrees to look solely to the League of Minnesota Cities Insurance Trust for reimbursement of all losses, costs and expenses arising under this agreement;and further agrees that in no event shall claim be made or asserted against the revenues or property,real or personal,of the League of Minnesota Cities. Acceptance of this agreement by the City constitutes acceptance of all terms hereof.e Le ze of Minnesota Cities Insurance Trust By -,1' Peter Tritz, Its Authorized Representative • • LM 4660 (12/03) Page 8 of 8 LMCIT Underwriting Satisfaction Survey As part of our ongoing effort to meet member needs and provide exemplary service,the League of Minnesota Cities Insurance Trust wLMCIT)is conducting this survey. Please take a moment to fill out this survey and return it in the enclosed, postage-paid envelope, ddressed to: League of Minnesota Cities, 145 University Avenue West, St. Paul, MN 55103-2044 Your comments will be used to make improvements to LMCIT operations. Name of city: Pd414- 1-1-s Please comment on your level of satisfaction with: 1. Overall quality of service provided by LMCIT's underwriting staff ❑ Extremely Satisfied ❑ Very Satisfied Jam Satisfied ❑ Not Very Satisfied ❑ Not At All Satisfied ❑ Not Applicable 2. Responsiveness of the LMCIT underwriter assigned to your city ❑ Extremely Satisfied ❑ Very Satisfied Satisfied ❑ Not Very Satisfied ❑ Not At All Satisfied ❑ Not Applicable 3. Explanation of LMCIT coverage changes regarding this renewal ❑ Extremely Satisfied ❑ Very Satisfied )( Satisfied ❑ Not Very Satisfied ❑ Not At All Satisfied ❑ Not Applicable 4. The LMCIT premium invoices you receive are clear and understandable ❑ Extremely Satisfied ❑ Very Satisfied pe Satisfied ❑ Not Very Satisfied ❑ Not At All Satisfied ❑ Not Applicable 5. Assistance you receive from LMCIT in preparing renewal documents ❑ Extremely Satisfied ❑ Very Satisfied g Satisfied ❑ Not Very Satisfied ❑ Not At All Satisfied ❑ Not Applicable 4111 6. Level of assistance you receive from your agent on LMCIT-related matters ❑ Extremely Satisfied ❑ Very Satisfied `ir Satisfied ❑ Not Very Satisfied ❑ Not At All Satisfied ❑ Not Applicable Over the course of a year,about how many times does your agent visit the city to discuss LMCIT-related matters? (please circle one response): 0 4100 2 3 4 or more Please identify the most important thing LMCIT could do to serve you better: f�, ..e..i'f tr Aft.1.4n,' �- . . • • n� LI . -moo e�r.t tut.i k..e-r K �' l v n ,r b.,/ 4 t 11:14._v . o n Cc C 1 att#V . • Questions or comments related to this survey can be directed to Lourdes Sanchez at 800.925.1122 or Isanchez @Imnc.org � Thank you for your assistance 13 ,. * • • • • i,pt • • • a '- ��- .Y • • .. i2 a v; # # ' vxra ' ..>.d..." r......�sg;a� ',a'''" ' ' .,.e:`✓ �y r am C^Y'' tt e a ''Pl it .b Y+ikr'7" 2 r1� 4 r` r x SA i ',sift �, 4 0 t} : r 'u tkA ra. „ ' „��s 1 ' ` %: s x gS' s ✓� h� r 4 e:w ? 3 z"''d.v, .t� ,. t i. 4 '� 15 r i 'x r�F S � „ "e..: x `t.* x .�7o x .. -Z,..-., +I$„ -5 " a'x4 x r r k N r . sx ' :"-a�rsr..., " x:a,..fl'e< 7a rAg-ii ?a ?..ma,4,x. ..,_ „„, ,. . x v � r qa� ;--• � k-Ci� = _ h City of Oak Park Heights O 14168 Oak Park Blvd.jc.. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: Lw1c aAsvrel et( e Tv .. 7y Fax: 105i - 2qt - \ 2 °11 From: G,I f Date: u,- Z 3_v Li, ir Re: Pages: 3 III CC: ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑Please Recycle Notes: 0_ , _ ._, ......_,. .-,_....-7 7:- -.17. '...—...:-... :::. . -::.:'.1..:',",--:;:,,"::: - League of Minnesota Cities Insurance Tru . � C [ 0 4' ., Group Self-Insured Workers' Compensation Plan Ind ; , 145 University Avenue West !;,�° 2 St. Paul, MN 55103-2044 ' ._ 0�;a ! t': hi RENEWAL DATA f` The "City:" OAK PARK HEIGHTS, CITY OF Agreement No. : 0200072917 PO BOX 2007 Quote To: OAK PARK HEIGHTS MN 55082 Quote Due On: 6/01/04 Agreement Expires: 7/07/04 Your coverage under the LMCIT Self-Insured Workers' Compensation program will expire soon. This Renewal Data sheet will be used to generate a premium quote for the different workers' compensation plans available. A copy of the City's previous year's selected coverages and premiums is attached for your reference. Coverage Options All of the options available to the City are outlined below, and described in the accompanying memo, Things to Think About When Renewing Your City's Workers' Compensation Coverage.You can select any coverage options in which the City may be interested. Premium quotes for all coverage options will be provided, and a final coverage decision can be made at the time you receive the complete quote. Elected Officials: Please indicate if the City would be interested in covering elected officials. Yes X No If yes, please list the estimated annual payroll for all elected officials the City would like to cover under workers' compensation. The 2002 premium rate for mayors and council members is$.37 per$100 of payroll. This rate is applied to the greater of either the official's actual salary or an imputed salary of$70 per week. Note: Coverage for elected officials requires a resolution passed by ity Council. Payroll Description Code Amount Elected Officials 9411 $ 26000 Members of Separate Administrative Boards:Please indicate if the City would be interested in covering members of separate administrative boards. Yes X No If yes, please select any separate administrative boards the City would like to cover under workers' compensation. (This coverage includes Board Members only.) 1. Utility or utility commission 5. Welfare or public relief agency 2. Port authority 6. School board 3. Housing and redevelopment authority 7. Joint powers board 4. Hospital or nursing home board or commission 8. X Other EDA, Parks & Planning commission(volunteers & sta cover specific Board Members above, the City can also Employees of Separate Administrative Boards:If the City has elected to ov r sp ifi y choose to cover type quote the City would like:q employees of those boards. Please indicate which t e of No quote for administrative board employees. Combined quote to include employees of both the administrative board and the City. Separate quote for employees of the City and each administrative board selected above. Volunteers: Please indicate if the City would be would like to cover City volunteers not designated as employees, such as Ohes, instructors, event workers, "clean-up" day volunteers, etc. (Volunteer firefighters, ambulance attendants, first reponders, enfozcement assistance volunteers, civil defense volunteers, and any other volunteers defined by s tatute as employees p y ees for purposes of work comp coverage are already covered and are not part of this election.) Yes No X (over) City Employees: Please indicate the estimated payroll for City employees for the coming policy year. The payroll descriptions and codes provided are the most commonly used. If you need to add additional payroll descriptions, please use the blank spaces and the illon the attached list. Sick, holiday, and vacation pay should be included in the payroll totals. Do not reduce payrolls for sick, holiday, and vacation pay. • Does your City have a flexible benefits plan such as a cafeteria plan, Section 125 plan, or flexible reimbursement account plan? Yes X No Employee contributios to a flexible benefits plan should be included in the payroll figures you provide. City contributions should not be included. (This is similar to how these plans are treated under PERA.) Payroll Description Code Amount Payroll Description Code Amount Ambulance Services (Not Volunteer) 7380 $ Sewage Plan 7580 $ 52014 Ambulance Services(Volunteer) 7381 $ Off Sale Liquor Store 8017 $ Building Operations 9015 $ Street and Road Construction 5506 $ 13870 City Shop and Yard 8227 $ Waterworks 7520 $ 86689 Clerical Office 8810 $ 349018 Other: Rink Attendants 90.16 $ 11372 Electric and Steam Power 7539 $ Other: $ Firefighters (Not Volunteer) 7706 $ Other: $ Firefighters(Volunteer) 7708 pop Other: $ Municipal Employees 9410 $ 749'00. Other: $ Parks 9102 $ 12136 Other: $ Police 7720 $678375 Other: $ Restaurant and Bars(on sale) 9084 $ Other: $ PREMIUM OPTIONS Please select the premium options below in which the City is most interested. All of the premium options selected will be quoted to City; however, only one premium option can be ultimately assigned for the coming plan year. Regular Premium Option: Please indicate if the City would be interested in the regular premium option. Yes X No Deductible Options: Please Indicate the deductible level and associated premium discount the City would like to consider. Deductible Premium Credit $250 3.00% $500 4.50% $1,000 6.50% $2,500 10.00% $5,000 14.50% $10,000 20.00% Retrospective Rating:Please indicate if the City would be interested in retrospective rating(if applicable). Yes No X Managed Care Option: Please indicate if the City participates in a state-certified managed care organization (MCO) for workers' compensation benefits, and if so, the name of that organisation. Yes X No MCO: Contact Information: Please provide us with a contact for questions about the City's workers' compensation coverage. • Contact Person Gary Brunckhorst Phone 651-439-4439 Email gbrunckhors t@citvof oakparkheights , corn Please fax this completed form to the League of Minnesota Cities Insurance Trust at 651-281-1297. If you have any questions, please contact Barb Meyer, Policy Services Technician, by phone at 651-215-4173 or 800-925-1122, or via email at bmeyer2 @1mnc.org. League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 Phone (651)215-4173 Notice of Premium Options for Standard Premiums of $25,000-$50,000 OAK PARK HEIGHTS, CITY OF Agreement No. : 0200072918 PO BOX 2007 Agreement Period: From: 7/07/2004 OAK PARK HEIGHTS MN 55082 To: 7/07/2005 Enclosed is a quotation for workers' compensation deposit premium. ESTIMATED DEPOSIT PAYROLL DESCRIPTION CODE RATE PAYROLL PREMIUM ilV"\- 1 r,v7 EE ATTACHED SCHEDULE FOR DETAILS 4 20 04 ill , Manual Premium 37544. • Experience Modification .83 Standard Premium 31162. Deductible Credit 0% . Premium Discount 2485. Net Deposit Premium 28677. MANAGED CARE CREDIT Cities that enroll with a state-certified managed care organization(MCO) receive a 3% premium credit on their work comp coverage. Standard Managed Care Net Deposit Premium Credit Premium 31162. 3% 27742. OPTIONS Please indicate below the premium option you wish to select. You may choose only one option and cannot change options during the agreement period. NET DEPOSIT PREMIUM ÔX Regular Premium Option 28677. or, with 3% Managed Care Credit: 27742. LM 4514(3/02 2. Deductible Premium Option Deductible options are available in return for a premium credit applied to your estimated standard premium of $ 31162. The deductible will apply per occurrence to paid medical costs only. There is no aggregate limit. IDDeductible Premium Credit NET DEPOSIT PREMIUM per Occurrence Credit Amount with MCO Credit without $250 3.00% 935. 26807. 27742. $500 4.50% 1402. 26340. 27275. $1,000 6.50% 2026. 25716. 26651. $2,500 10.00% 3116. 24626. 25561. $5,000 14.50% 4518. 23224. 24159. $10,000 20.00% 6232. 21510. 22445. 3. Retrospective. Rates Premium Option Retro-Rated Est.Minimum Retro-Rated Est.Maximum Minimum Factor Premium Maximum Factor Premium .919% 28638. 1.150% 35836. .852% 26550. 1.250% 38953. .755% 23527. 1.500% 46743. This quotation is for a deposit premium based on your estimate of payroll and selected options. Your final actual premium will be computed after an audit of payroll subsequent to the close of your agreement year and will be subject to revisions in rates, payrolls and experience modification. While you are a member of the LMCIT workers' Compensation Plan, you will be eligible to participate in divident distributions from the Trust based upon claims experience and earnings of the Trust. • If you desire the coverage offered above, please return this signed document for the option you have selected. This quotation should be signed by an authorized representative of the city requesting coverage. , ..41/111/ ci T i7iivf5/2 D2, 4-21 V 'nature Title Date • S LM 4513(3/02, League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 Universit y Avenue West St. Paul, MN 55103-2044 (651)215-4173 Me "City" Agreement No. : 0200072918 Agreement Period From: 7/07/2004 OAK PARK HEIGHTS, CITY OF To: 7/07/2005 PO BOX 2007 OAK PARK HEIGHTS MN 55082 CONTINUATION SCHEDULE FOR QUOTATION PAGE REMUNERATION RATE CODE DESCRIPTION EST. PREM 140203 6.27 5506 STREET CONSTRUCTION 8791. ) 625425. 3.61 7720 POLICE 22578• �' '374603. .54 8810 CLERICAL OFFICE EMPLOYEES NOC 2023. 10849. 2.26 9016 SKATING RINK OPERATION 245. 90677. 2.86 9102 PARKS 2593. y (so,o°° _ 124343. .98 9410 MUNICIPAL EMPLOYEES 1219. — 25583. .37 9411 ELECTED OR APPOINTED OFFICIALS 95. Manual Premium 37544. • Agent: 411709883 00874: FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST FOREST LAKE MN 55025- • 6/09/2004 LM 4680(8/99) Prey. Yr 04' 05' Holiday Overtime 04' + 05' earings Council David Beaudet 3,000 3,000 $ 6,000 $ 6,000 Les Abrahamson 2,500 2,500 $ 5,000 $ 5,000 411 Doer 2,500 2,500 $ 5,000 $ 5,000 McComber 2 500 2 500 5,000 5,000 ark Swenson 2,500 2,500 $ 5,000 $ 5,000 Total $ 26,000 $ 26,000 9411 Part Time Parks Andrew Kegley 11,320 11,660 $ 22,980 John Sortedahl 2,613 2,939 $ 5,552 Jeff Brown 1,442 $ 1,442 Tamara.Chastain 692 $ 692 Nina Kellogg 829 $ 829 Mark Wolf 637 $ 637 Amy Engleman 1,315 904 $ 2,219 Total $ 34,351 9102 Police Stanley Buckley 30,449 31,362 2,906 1,781 $ 66,498 $ 63,243 1.05 Michael Hausken 34,521 35,557 3,051 390 $ 73,519 $ 70,219 1.05 Lindy Swanson 41,586 42,834 1,599 $ 86,019 $ 82,104 1.05 Kenneth Anderson 31,385 32,326 3,278 679 $ 67,668 $ 65,022 1.04 Paul Hoppe 34,521 35,557 3,173 - $ 73,252 $ 70,307 1.04 Fred Kropidlowski 30,449 31,362 2,691 1,985 $ 66,487 $ 64,525 1.03 Brian DeRosier 30,213 31,120 3,278 - $ 64,610 $ 62,322 1.04 Joseph Croft 30,171 31,077 2,906 5,369 $ 69,523 $ 62,169 1.12 id Kisch 30,171 31,077 2,799 229 $ 64,276 $ 61,294 1.05 ra Kruse-Roslin 22,917. 23,605 $ 46,522 $ 44,502 1.05 Total $678,375 7720 Office Staff Gary Brunckhorst 25,493 26,258 - $ 51,751 $ 49,817 1.04 Judy Holst 39,352 . 40,532 757 $ 80,641 $ 86,109 0.94 Julie Hultman 22,917 23,605 881 $ 47,403 $ 45,800 1.03 Eric Johnson 39,018 40,188 - $ 79,206 $ 51,520 1.54 Julie Johnson 21,235 21,872 816 $ 43,923 $ 42,027 1.05 Lisa Taube 22,706 23,388 - $ 46,094 $ 43,923 1.05 Total $349,018 8810 Building Insp. Jimmy Butler 32,626 33,605 $ 66,231 $ 63,352 1.05 9410 Breakdown Public Works Jeff Kellogg 25,493 26,258 7,240 $ 58,991 $ 56,750 1.04 -5506 13,870 New Hire 25,261 26,019 485 $ 51,765 $ 77,692 0.67 57520 86,689 Mark Robertson 16,817 17,322 5,504 $ 39,643 -7580 52,014 -,--7720 678,375 Total $150,399 -8810 349,018 Public Works Breakdown -.9102 12,136 5506 8% $ 173,378 12,136 Parks -9410 74,900 7520 50% 13,870 Streets -9411 26,000 7580 30% 86,689 Water 9016 11,372 • 9102 7% 52,014 Sewer 9410 5% 8,669 Storm Sewer 1,304,374 1 11,371 Parks Workers $ 1,304,374 , Prey. Yr 04' 05' Holiday Overtime 04'+05' earings Council David Beaudet 3,000 / 3,000 / $ 6,000 $ 6,000 Les Abrahamson 2,500 / 2,500 / $ 5,000 $ 5,000 40Doer 2,500 / 2,500 / $ 5,000 $ 5,000 McComber 2,500 " 2,500/ $ 5,000 $ 5,000 Mark Swenson 2,500/ 2,500 / $ 5,000 $ 5,000 Total $ 26,000 Y$ 26,000 / 9411 Part Time Parks Andrew Kegley 11,320 11,660 / $ 22,980 / John Sortedahl �4-r3 2,7T2- ?;85S 29a9 / $ 57627 s,SS.- Jeff Brown I,, 4/ 1,442 -- $ ?,842 1, 1 Y -- Tamara Chastain E ' 692 . ' $ .1fa$11 6.9�- Nina Kellogg / 829 - $ 6e 9 �y Mark Wolf l 637' $ x,2545' Ca 3 7 Amy Engleman 5,,.-.,-..-- 2I _5Ni $ 1rr0&A' .,.-1 j 1 3 1< ,oL Total $ X:1-760- 3`, 3 S/ 9102 Police / i VI / Stanley Buckley 30,449 31,362 / 2;846A/4. 1,451 :$ •6,077 $ 63,243 1.04 Michael Hausken 34,521 / 35,557/ 27955 3 OS/ 39S/ ,423 $ 70,219 1.05 Lindy Swanson 41,586 /42,834 / 1;560141 8,,975 $ 82,104 1.05 Kenneth Anderson 31,385/ 32,326 / v115 3277 1.,08409$ 6 ,9 9 $ 65,022 1.04 Paul Hoppe 34,521 (35,557/ 3 3173 3$3n 73 5 1 $ 70,307 1.05 Fred Kropidlowski 30,449 /31,362 / 21.696 449) 2,94215 67, 59 $ 64,525 1.04 Brian DeRosier 30,213 / 31,120.' 3+75 Y- se 0 $4 65 ,35 $ 62,322 1.05 Joseph Croft 30,171 / 31,077 / 2781-5'. 94 94'8,x16$ 6,,•81 $ 62,169 1.05 PERO Kisch 30,171 /31,077 / 24-1 a1 Gil 14701$ •',1.6 $ 61,294 1.05 ra Kruse-Roslin 22,917/23,605 / 0,2- $ f°6,5'5 $ 44,502 1.05 Total $67 , 6 7720 Office Staff Gary Brunckhorst 25,493/26,258 / -° $ 52,658 $ 49,817 1.04 Judy Holst 39,352/ 40,532/ •747 1.393' $ .8-1-,-277 $ 86,109 0.94 Julie Hultman 22,917 /23,605 / $$/ 1,392-- $ 4Z18g- $ 45,800 1.04 Eric Johnson 39,018/ 40,188 " - $ 79,206 $ 51,520 1.54 Julie Johnson 21,235 1 21,872 � 9/4 7.93- $ 4,,.96T $ 42,027 1.04 Lisa Taube 22,706 / 23,388 / - $ 46,094 $. 43,923 1.05 Total $3 59 8810 Building Insp. Jimmy Butler 32,626 /33,605 / $ 66,231 /$ 63,352 1.05 9410 Breakdown Public Works Jeff Kellogg 25,493 /26,258/ j,240/$ 58,991 '$ 56,750 1.04 5506 13,957 New Hire 25,261 / 2¢,-982 .2c;0 i 9 lig..0 I488- $ 52809 $ 77,692 0.68 7520 87,232 Mark Robertson 16,817/ 1,7/26-4 /7 3 z..,., 5,504 $ 3.94136 7580 52,339 7720 675,026 Total $151,485 8810 350,359 Public Works Breakdown 9102 18,900 • 5506 8%"$ 1!74,465' a 12,213 Parks 9410 74,954 7520 50% i10 13,957 Streets 9411 26,000 7580 30% 55/`74, 87,232 Water 9016 7,094 9102 7% 3d7a 52,339 Sewer 9410 5% 3 1 8,723 Storm Sewer 1,305,861 13,780 Parks Workers $ 1,305,861 i 2003 Holiday Pay Base Hours per Hours Per Holidays Pay Month Day Holidays Worked Kenny Andersen $4,734.45 173 8 10 9 $ 3,174.54 Stanley Buckley $4,509.00 173 8 10 7 $ 2,814.87 Joseph Croft $4,509.00 173 8 10 7 $ 2,814.87 Brian DeRosier $4,734.45 173 8 10 9 $ 3,174.54 Michael Hausken $5,112.67 173 8 11 3 $ 2,955.30 3it)Paul Hoppe $5,112.67 173 8 11 4 $ 3,073.51 David Kisch $4,509.00 173 8 10 6 $ 2,710.61 i j Fred Kropidlowski $4,509.00 173 8 10 5 $ 2,606.36 G,t $23,324.60 40 411