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HomeMy WebLinkAboutUntitled (3) ACORD INSURANCE BINDER OP ID KT 07/01/03 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT,SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. PRODUCER PHONE COMPANY BINDER# 781 (ac,No,Emy 651-464-3333 651-464-7596 LMCIT-Berkley Risk Services, I_ EFFECTIVE EXPIRATION Landmark Insurance Services DATE TIME DATE TIME 232 South Lake Street X AM X 12:01 AM Forest Lake MN 55025 07/07/0 12:01 t PM 07/01/04 NOON Landmark Insurance Services THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE A:.' r�� ID COMPANY CODE: SUB CODE: X PER EXPIRING POLICY#: CMC2 2 97 7 AGENCY DESCRIPTION OF OPERATIONSNEHICLES/PROPERTY(Including Location) CUSTOMER ID: OAKPA-1 INSURED City of Oak Park Heights All city property, Autos and Equipment Eric Johnson, City Admin based on current (2003) schedule provided y , by the city. 14168 Oak Park Blvd PO Bx 2007 Oak Park Heights MN 55082-6476 ) COVERAGES LIMITS TYPE OF INSURANCE COVERAGE/FORMS DEDUCTIBLE COINS% AMOUNT PROPERTY CAUSES OF LOSS BLKT BG/PP 500 per schedl BASIC BROAD X SPEC X Replacement Cost GENERAL LIABILITY EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $50,000 X CLAIMS MADE OCCUR MED EXP(Any one person) $1,000 PERSONAL&ADV INJURY $1,000,000. GENERAL AGGREGATE $1,000,000. RETRO DATE FOR CLAIMS MADE: 07/07/87 PRODUCTS-COMP/OPAGG $1,000,000. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000. _ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS MEDICAL PAYMENTS $ NON-OWNED AUTOS PERSONAL INJURY PROT $ X $500 DEDUCTIBLE UNINSURED MOTORIST $1,000,000. $ AUTO PHYSICAL DAMAGE DEDUCTIBLE X I ALL VEHICLES SCHEDULED VEHICLES X ACTUAL CASH VALUE X COLLISION: 500 STATED AMOUNT $ X OTHER THAN COL:— 500 OTHER GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $1,000,000. X UMBRELLA FORM AGGREGATE $1,000,000. OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: 07/07/87 SELF-INSURED RETENTION $10,000. WC STATUTORY LIMITS WORKER'S COMPENSATION E.L.EACH ACCIDENT $1,000,000. AND EMPLOYER'S LIABILITY E.L.DISEASE-EA EMPLOYEE $1,000,000. E.L.DISEASE-POLICY LIMIT $ SPECIAL Open Meeting Law - $1,000,000.; Crime - $100,000. w/$500. ded FEES $ CONDITIONS/ OTHER TAXES $ COVERAGES - ESTIMATED TOTAL PREMIUM_ $ NAME&ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN# AUTHORIZED REPRESENTATIVE • ode.:00,464:16„ rivie4nde ACORD 75-S(1/98) NOTE:IMPORTANT STATE INFORMATION ON REVERSE SIDE ©ACORD CORPORATION 1993 LMCIT LIABILITY COVERAGE -WAIVER FORM Cities obtaining liability coverage from the League of Minnesota Cities Insurance Trust must decide hether 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 $1,000,000., regardless of the number of claimants. . If the city waives the statutory tort limits and purchases excess liability coverage, a single claimant could potentially recover an amount up to the limit of the coverage purchased. The total which all claimants would be able to recover for a single occurrence to which the statutory tort limits apply would also be limited to the amount of coverage purchased, regardless of the number of claimants. Claims to which the statutory municipal tort limits do not apply are not affected by this decision. This decision must be made by the city council. Cities purchasing coverage must complete and return .(is form to LMCIT before the effective date of the coverage. For further information, contact LMCIT. You may also wish to discuss these issues with your city attorney. The City of 0.A. NA)tr... (4+s accepts liability,coverage limits of$ 1100 o coo• 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 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. Date of city council meeting 5 G(u. c -2 `r'0 Signature Position /446ni,il s'fr'eti o r— Return this completed form to LMCIT, 145 University Ave. W., St. Paul, MN. 55103-2044 ebeks6 Page 1 of 1 {fir LEAGUE OF MINNESOTA 145 Unive 'i" G:0dVVe..■ St. Paul -' (651) ra tJ a P, . Paq, 2.col APPLICATION FOR THE CITY OF: OA. Pa -462-1000 County: itJ2,kg *W\ Mailing Address: ( t Phone: 451'teat 4.4 39 City, State, Zip: 0 )&'2 -(0 ci 7c City Contact: C� O / w c cfe.cr, $ 1990 Census Population: 3 Lf t4(9 Current Ccnsas- 7 5a.. 3`I Total Expenditures All Operations: , /C�"6 'Y�s . , , , _- ~ ��f Is the City a Member of The League of Minnesota Cities? X Yes No ?-9/ t.r-4- Submitting Agency: Loh,49.+ 04-1/ k l h.S0-wCv"ca, SeAr vzr-Pla '� "`)y Address: 2 3 2 Lac-c- 5 �t.* So •-tom 'n- City, State, Zip: �CV,e� Lea � Ai rj s 0 2 Telephone: ((o Si) `f(p c " 3 3 3 3 Facsimile: ( CPS I ) '(Co " "65(p Agency Contact: 6>e : r Date of Council Resolution or Contract Appointing the Agency: AGENT COMPENSATION: x 10% City Will Compensate the Agent Directly Other Please specify: Standard Deductible: 00 ' (Applies to All Lines. Optional All Lines Deductibles are Available.) Current Information on Coverage You Are Applying For: Carrier Policy Type Expiration Date Premium C,Mc 1 1P 7-7-0 3 wcl v„„b 1 0/145 5 LMCITAPP.TBL(11/97)(REV. 11/00) PAGE 1 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PROPERTY/MOBILE PROPERTY COVERAGE Blanket Limit of Coverage Per Occurrence to be established by LMCIT. -°' This limit is established by totaling the replacement cost values of all your buildings/contents, property in the open and mobile property. BUILDINGS/CONTENTS/PROPERTY IN THE OPEN Attach updated schedule of buildings/contents,and property in the open. MOBILE PROPERTY- GREATER THAN $25,00 Attach updated schedule of mobile property with replacement cost values greater than$25,000. MOBILE PROPERTY-$25,000 OR LESS Mobile property with replacement cost values of$25,000 or less can be covered with no schedule. There is a flat premium charge. Do you want this coverage?(YES [ ]NO 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.30(11/97)(REV. 11/00) PAGE 2 OF 19 r 4 N .e 0 a@ I ,. , . co 1 e'r I. ■ off.. 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C,1 • , ..1.4. • ,. • -U 0 Z 1 r.• . 0 La La 4 C-4 CC 3 0 • a" . ..:, - z f......!c-..! . 0 c. , . z . . . . , U • . . : E0 z . : . . • . . . i . . ; : . . . ! . ; . . $- ,• .i . , Ls • . . . <.z . • . . . . . . • z CC Z * . ; z -= . . . . . CP-4.- • . . 0 -4 0 r LI 0 La U 4 Lt . r 0 ILI . fr - "-:3 Z CI - 1-•■ 0 Li- `, 0 •,0 .• r CO ze • to t-o •-, • La Z Z i • ir 0 •Ct 4 0 0 . , • .. fl'; . , ... „ , • , . . (..).- ::. , ;:‘;..!.) tf, Co; r-• n CC tt 0 III■____ • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST WATER AND SUPPLEMENTAL FLOOD COVERAGE APPLICATION I. Does your city have any locations in a flood hazard area? 1/1.0 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 maximum amount of insurance available for the LMCIT Supplemental Flood Coverage to be available. Please contact your Underwriter for further information. 1 1 rn,r r} r el " It �r,� 4�f��� nj �: 1 1 .iS ,q �3a�5 f`�._.._.. u:� t y ,.�. a_.1��� ��°� �d,.b._ eta.. LMCIT.APP(11/00) • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PROPERTY The covenant provides Errors and Omissions coverage for Property. The following information is needed to designate the entities that are to be covered. Please indicate if you want the following entities to have coverage for Property Coverage. r?� sl LI F 1 9 HOSPITALS YES NO N/A, NURSING HOME YES NO N/A HEALTH CLINICS YES NO i N/A II AIRPORTS YES NO r N/A I ELECTRIC UTILITY YES NO N/A GAS UTILITY YES NO_ N/A STEAM UTILITY YES NO— N/A X. HRA YES NO X N/A EDA YES X NO_ NIA PORT AUTHORITY YES NO N/A ADDITIONAL INFORMATION: LMCITAPP.11(11/97)(REV. 11/00) 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 oZ & i1 t ? go Debt Service yqo 1 � Enterprise Fund /Co ir L/0 Port Authority Special Revenue Funds -7 a 0-0 Nursing Homes 0 Capital Improvement Funds 7 7 7 Hospitals v Airports Clinics HRA ,d Other(please describe) 0 EDA Line II Transfers 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 Adjusted total expenditures is the total expenditures for those departments and operations that have E&0 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 Service(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. PLC`SE ATTACH A COPY OF THE LATEST CPA AUDIT AND/OR THE PROJECTED BUDGET(WHICHEVER REFLECTS THE EX. ..QDITURES ON THE WORKSHEET). THIS INFORMATION WILL ASSIST UNDERWRITING IN ANSWERING ANY QUESTIONS WITH REGARD TO THE EXPENDITURES WORKSHEET. LMCITAPP.0(I I/97)(REV. 11/00) PAGE 4 OF 19 LMCIT EXPENDITURES WORKSHEET nn G � .6 �-05 0 3 City d�Qf. 'l Wl�,, ► Budget Year All Expenditures �, 3.j /3'7 Transfers .2 Co$ 6,05" III. E&O 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) V. GL Deductions a) Contracted Services b) Debt Service / 90/ c) Water Department Only a.3,3 6.0,C 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) 1) 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 O S A/O.( LMCITAPP.1 I (11/97)(REV. 11/00) PAGE 5 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 10. Municipal liquor store receipts: Ina Store 1 Store 2 Store 3 On Sale Off Sale 11. Number of seasonal swimming pools: Y` 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: Height: Length: Location: Seasonal: Year Round: 15. Does the pool(s) comply with the Minnesota Dep nt of Health revised Chapter 4717,Public Swimming Pool Rules effective January 4, 1995, conc ruing water depth requirements for diving boards and pool decks? Yes No 16. Number of staff attorneys: hOhQ. Do you want coverage to be excluded? Yes No Additional Information May Be Necessary 17. Does the City want to exclude medical payments? Yes No LMCfTAPP.01 (11/97)(REV.11/00) PAGE 7 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 10. Municipal liquor store receipts: 144 Store 1 Store 2 Store 3 On Sale Off Sale 11. Number of seasonal swimming pools: l^ Height of diving boards: 12. Number of inside swimming pools: Height of diving boards: g g 13. Number of swimming beaches: Height of diving boards: Number of docks and rafts: 14. Number of water slides: • Height: Length: Location: Seasonal: Year Round: 15. Does the pool(s)comply with the Minnesota Dep nt of Health revised Chapter 4717,Publ; Swimming Pool Rules effective January 4, 1995, cone ruing water depth requirements for di boards and pool decks? Yes No 16. Number of staff attorneys: VtiQ".Q. Do you want coverage to be excluded? Yes No Additional Information May Be Necessary 17. Does the City want to exclude medical payments? Yes LMCITAPP.01 (11/97)(REV.11/00) • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST MUNICIPALITY QUESTIONNAIRE DO NOT LEAVE ANY SPACES BLANK IF NO EXPOSURE PLEASE INDICATE N/A OR NONE City of 0494' 1)0 1 Date Co- 1 O 3 1. Does the city own or operate any of the following? u �^^,,.+` r ,..r" ilt�' vMl W�+;.,{ it l+i 7 i urv,.r R r",L i r y • "1'� i ,it � t�, - lr • rt +r h'�if<, ' ! a �Y++ffe,4 �a)"1 r �4 r I' ,'S “A t k . rr!�� fil>, 7R �.v�` {;;,' (�1� .1,�'r� r;.i 1 i'Yl }r 7F-,..�. ^,F R4f .,° c�lY ,.rl T t aj r tl r 1 I' 1 { j 'l:ti nL�i.1r,�Ymrgr 1.fi �t �,..: ii Y ._„ 1 .; .,`T Grlf llau rh ^7 ..a':, , F t'.. r. .. r{:i�. I_h �l 1 vJ �1 � ��'I 1�1f h 4j 4'C�;, �I �f � � .I � � ��,�ll � e :. �3�)0C':+0 �B�! qb 3. � &E1�1iFI S0l"f� .�k'(� 11 'rbFl `a( �}��f ".�I� 7G'!��$A� � a,,.,i�t (1���M Iz 4X��rH�S,h ti„�au_f •�^�r2 �. r _ 7 e:.. � s 1 v s a„��✓ z s 1.;C 1 rl S arm--N.' r 41 ti,,( 1 v :Ih r t d r, t 4( .,ti r { r r r l 5 .4. s _r iJ'.�f. 1 ii1 �7 1" .tl r_l. 9 ae' .,}w� 11'1 I Ni POP o fill' �7t5tk,41 sG'f�)r o dL r :(��� 7! 11-J C" �r-!�1.xa41{� iliE -'p §.4"k rs r eR ". ej :i �!'�14r S (. S, kip 6,gya r i;��. i I1 .�-! ,LI��'�f,.rl�i l �r' I. I e �} Je. , ! 1 t ��1�`'t 'yl�l r 4 it j, �,t t. t� !0 �.E/ ` i,:>!f 1 —�- A >u " :114, �{�� r5}1„;1,','.1,1.1„ r y[a� to •1 4 �{ t 1 arA t ..y.ti yr k c ni, {.: , ,,.i>r�(ij�V ern ?_Ci�-k �.., t Hospitals _Yes X No _Yes _No Nu. .,g —Yes „ No _Yes No Homes Health _Yes 'C No _Yes No Clinics Airports Yes No _.-■ Yes No Comments: * Municipal Liability, except for bodily injury.propel-Li damage or personal injury,, is automatically provided for the City 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 t City and the other Governmental Body or Entity. LMCITAPP.02(11/97)(REV. 11/00) 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 i Fa-.si i.?.-,t' i ia f, , :.. j If k 1 ' �� ° Y r i . ? a1 i :5 r s `.: a% ,�r 2MOLO ! .1, 81-3 � { t.1(4.', G f yW' Gas Utilities Commission _Yes X.No Questionnaire Needed Electric Utilities Commission Yes No Questionnaire Needed Steam Utilities Commission Yes No Questionnaire Needed Port Authority _Yes No Need Full Details Housing&Redevelopment Authority _Yes Y No Need Full Details Economic Development Authority X Yes _No 1 ? 08" pD Need Full Details Area or Municipal Redevelopment Yes _No Need Full Details Authority Municipal Power Agency Yes No ■ Need Full Details Municipal Gas Agency _Yes _No Need Full Details Ect a .!� ., .. z. w. .. �l Z'=- L -- /!W 4,- I s Tr0.55 0....k.A3H-/ 64? . " • LMCTTAPP.02(11/97)(REV. 11/00) PAGE 9 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 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? �P r 4�1f�61o,' 7, uL.s�:ff1'�ain.� 7...w' �.rvrImowyue,f�,.,:'l ,.�r' r,.r m17��r aa..' �i�.�,. ?° II 1I JAdL, 71F-77 -ri lT f tl B gi L)1:1.t r� l (. 'e 0 �za}Y j�JIr f j�y 7J a e a t R to- Welfare or Public Relief Yes ,,No Need Full Details Agency ,. School Board _Yes .X No Need Full Details 4. Does the city operate a dump or landfill? What type of material is deposited there? Is the area fenced to keep out the public when closed? 's the area attended during open hours? city own or operate a marina? Y the ci o >: 5. Does named as an additional insured on their policy and the If operated by others, please indicate and advise if the city is nam P Y policy limits provided. Is coverage desired? Yes No If coverage is desired, full details must be submitted. I.MCITAPP.02(11/97)(REV. 11/00) PAGE 10 OF 19 • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 6. Dams classified as Class I or Class II by the Commissioner of the De,partment of Natural Resources or any dike, levee or similar structure- (Failure or bursting is excluded.) A. Age of Dams: Inspected regularly: Yes No 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: w(0.. 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: 7. Describe any large construction projects anticipated for this coming year. lilLea-VT - (A.-+-).I,. r v '1--.-S below s a, 'e C`{t:.. e ofopCoXi//7tN.. -y AS/ /ivJ`kg. uPr i.fS 8. Parks..and Playgrounds A. Description (including area) of each park or playground: e4).".4-9-. t I nes B. Description of playground equipment on each: t c n ( � O LMCITAPP.02(11/97)(REV. 11/00 PAGE 11 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 9. Does the city 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 g may be available. Does the city 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 No B. Amusement devices, with a power motor greater than 5 H.P (Excluded) Yes No C. Beer booths (Liquor Liability is excluded. Refer for consideration) Yes No D. BMX tracks Yes No E. Climbing Wall Yes No F. Dunk Tanks Yes No G. Festivals, parades and exhibitions Yes No H. Fireworks (Excluded. Refer for consideration.) Yes No I. Rodeos (Excluded) Yes No 3. Skateboard Parks Yes No K. Ski jumps, ski lifts and tow ropes Yes No L. Toboggan or Tubing Slides Yes No M. Trampolines Yes No If any of the above are operated by others, please advise if the city is named as an additional insured and the -policy limits provided. (Continued next page) LMCITAPP.02(11197)(REV. 11/00 PAGE 12 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 10. Special Events/Risks (continued) Details: 11. Firefighters 0.4ivac ,c.cl. 4044 wxvtcxr4 p C; Payroll of paid firefighters: Number of volunteers: hc4- Number of fire trucks: 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.02(11/97)(REV. 11/00) PAGE 13 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 13. Law Enforcement Total law enforcement payroll: G L? 700 (-°'( ` CI /6 ) i Number of law enforcement vehicles: Number of Employees by class: Class A (Full-time): A (Part-Time): 0 Class B: 0 Class C: d Class D: 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: Ov1.1. Describe any jail or detention facilities maintained: ( catt- C : - Maximum holding period: cu, ci2f2cr.A.S 14. Grandstands and Stadiums A. Number and location of each: �" 1 .2.� - ?4..Ar C- ( .eit _' B. Seating capacity: I(Q O C. Type of construction: .pa D. Permanent or temporary: j.t,v 15. Wharf or Docks - Describe: InG�•t. LMCITAPP.02(11/97)(REV. 11/00) PAGE 14 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 16. Street or Road Construction or Maintenance Annual expenditures: If 1; 0c2 O - cd..2_C How much work is sublet to others? ctf2.L S r r.c.60w4v1- Are Certificates of Insurance obtained indicating adequate limits? Is any blasting done? ^CS' 17. Please describe any contractual agreements the city has entered into such as: A. Mutual aid: (Jv ___ d4U'. C- B. Police or fire protection: / + F C. Other. Describe: 18. Dint 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. ce from all independent contractors? 19. Do you routinely get Certificates of Insuran ep Y 20. Does the city provide a fire alarm or burglar alarm protection system? LYr If so, please give full details. C.i 4,4./ 6-te .�.A �crLr'- fr t- 1( 21. Any other pertinent information not covered above: LMCITAPP.02(11/97)(REV. 11/00) PAGE 15 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 22. City was created in: 91'1 (Year) 23. Names and official titles of the Members of the Board of the City: (City Council) Name Official -04,v/o1 eax.u.d.et N' Le s 11lorr.harnsor'- cal 14,%Qw►A .Tc�c(< -Po err Mary ,4t i1larlC ..S W &sort 24. Fiscal Year *Revenue *Expenditure Fund Balance At Year End ,iii Projected Year , , `l / 1-/kg /zv ,590 7�3 A007- .� "7afr0 Current Budget / o 1st Prior Actual H1 --z--264 2' S. � 'o 1( •/ C a Vi (ABS p°D 2nd Prior Actual y 7"VI (D2fo/ S2:71 , oft(7 T140 . 19 9A 3rd Prior Actual 5,iq g ig 2-+P• 7 o3(# ( 55 • fete 5 7i l(o g *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. g. Total amount of outstanding bonds: 2.-70 040 b. Latest Moody's and/or Standard and Poors' bond rating: A 2 - ftoac 4, LMCITAPP.02(11/97)(REV. 11/00) PAGE 16 OF 19 • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST Have any of the following situations occurred within the last five years? Yes No a. Appropriation or condemnation for which agreed , settlements have not been achieved. b. Improper or alleged wrongful granting of variances, building permits or similar grants or zoning disputes. c. Wrongful or alleged wrongful approval of building plans, designs or specifications. d. Wrongful or alleged wrongful approval of building construction. e. Allegation of unfair or improper treatment regarding employee hiring, remuneration, advancement or termination of employment. f. Disputes involving integration, segregation, discrimination or violation of civil rights. g. Any grand jury indictments of any public officials. h. Assault and battery claims made against the municipality or its officials. i. Any riot or civil commotion in the past five years. j. Any losses or claims occurred involving contractual disputes. 27. Land Use Liability Number of building permits issued: 41 2 Number of variances: Granted Denied Number of conditional use permits: Granted tt' Denied 0 28. Has the City submitted their Comprehensive Plan to the Metropolitan Council for review and comment? Yes X No Has the Metropolitan Council reviewed the plan and made their comments? Yes )1 No Are you a participant in the Metropolitan Council Livable Communities Program? Yes u No What year did you join? 1' 1(v LMCITAPP.02(11/97)(REV.11/00) PAGE 17 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 29. Please list the additional covered parties required. hO►L« 'i�Y}1�y q.c.,'r�4,4tAT a�i t'_L,-�t�1 '�r °d��t�3 �G'C�e�,��iy In�il� {..a 4A(������� � °v� i-1� L ,�yl V,1{ � q{q{ I t , t�`� IL,1,01,k7 1 ADDITIONAL COVERED NAME ADDRESS PARTIES INTEREST 30. Contracts with a railroad and contracts with the contractor performing 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 project. PAGE 18 OF 19 LMCITAPP.02(11/97)(REV. 11/00) LEAGUE OF MINNESOTA CITIES INSURANCE TRUST AUTOMOBILE LIABILITY AND PHYSICAL DAMAGE CITY OF 0a ?a`'`r 1. COVERAGES: A. Liability: Limit: $1,000,000.Combined Single Limit on Bodily Injury and Property Damage B. Uninsured and Underinsured Motorists (indicate limit desired) $50;000. Uninsured and Under insured Motorist Limit* or X $1,000,000.Uninsured and Under insured Motorist Limit *The standard limit is$50,000. The City may increase if they chose. C. 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. Cities have the option to make their LMCIT Liability Coverage primary for vehicles used by specified individuals or groups in specified circumstances. Please indicate if you want this optional coverage and provide additional information requested Yes X No I. 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 city needs to submit an accurate listing of vehicles for the renewal. The city's premium for auto liability and physical damage coverages for the entire year will be based on the schedule of vehicles the city 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 l=Lime Yellow;2=Red;3=All Others TttTTTodTs(he ahed computer pintout vies current Schedule. However, recent changes may not show on the 11 ��v� `'t.71 ;� iI �r.''� r'54-"5;-��Y 4e�r \T�t A1'7 �d .�� L ^41`Q � .�y.}�>7� +�',i 1 ,f CO 44 •�, �t S"' v i a r� '..s �f l t�:!� + 4 c k'r`a- a .: i I BLS i� 11 k � �`�e rr � i II-� y � s'_4 � i i k o t a { II�.i if ,Yl?� r�rt�.•t.,..un'. Na t-?tf lz { r 'tr 2 �Mt�. 11114 it lv��1 ti o �e `�-}��>pl�t' it rr� � �{ " i`r' 'i^;�T r'Y •w Mtii§:n,-` 67 'h,: •r k nt'-e7q,;AS sti45 41' ., i.� Yw'psi S.Yl i.1 fib.tip=1 T,',.:1';' � F ^ L'�,-)i*Z � t1�• I r��b��6,a.:..,.,��a. 2 3 ;MCITAPP.15(11/97)(REV. 11/00) PAGE 19 OF 19 .0 W o <O C W W ! p <• 0 Z U 6 J J M a J J 6 J J Q. J J N 0. 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Q O n 0p▪ < 0 O Oml Oml T N 4 O L > 0 0 .mod N Cyr W 4. W U u .4 N N .4 .4 1 0 0 W OI OI N ner n T 01 U N M N .! U O Z U. U LL O s I- M 0 u N V m I- * z 0 W M 0 O `S W_ Y n O 0 es os W < N CC 0. N 0 • VI Y • Z < o O w 0 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 city have an inspection and maintenance program?[f Yes [)No Please describe briefly or attach a copy of the program. 2. Problem area identification procedures Does the city 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 city have a procedure for providing 24-hour/7 day emergency response to sewer back-ups? 11 Yes [) No Please describe briefly. 4. Inflow and Infiltration Procedures(Storm water getting into the sanitary sewer system) Does the city have an active plan to minimize the effect of storm water getting into the sanitary sewer system? [)Yes f)No Please describe briefly. LMCITAPP.SEWERBU(11/00) 5. Documentation Does the city maintain written records of its normal maintenance and inspections of the sewer system? [] Yes [] No Does the city maintain written records for its cleaning and inspection of problem sewer lines? [J Yes[jNo 6. Planning Does the city have capital improvements planning in place to remedy any ongoing problems with its sewer system? [l Yes [j No Please provide details including a description of the plan,availability of financial resources and timetables. 7. Special Note: No fault Sewer Back-up Coverage cannot be bound until the city 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) LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PT` -IC EMPLOYEE DISHONESTY OR PUBLIC EMPLOYEE FAITHFUL PERFORMANCE COVERAGE APPLICATION ADMINISTERED BY: BERKLEY RISK ADMINISTRATORS COMPANY,LLC 145 University Avenue West St. Paul, MN 55103-2044 Limit of Coverage Per Occurrence: (Deductible) • Bond Employee Dishonesty Coverage: $ 1001000 • (Standard) • Bond-Employee Faithful Performance Coverage: $ t 001000 . (Standard) • Option: The city may choose to have employee dishonesty or faithful performance coverage for specified positions. Please contact your LMCIT underwriter for additional information. 250,000 (4ast,20oo awe,) AUDITS: FREQUENCY: BY WHOM?: CPA X STAFF AUDITOR OTHER(Explain Fully) DATE OF LAST AUDIT: /� 1��02 DISCREPANCIES?: YES NO (If YES submit copy of audit or auditors comments.) LOSS HISTORY(LAST 5 YEARS): EMPLOYEES POSITION WHICH CAUSED LOSS: CORRECTIVE MEASURES TAKEN: WILL THERE BE A SUBSTANTIAL INCREASE IN THE NUMBER OF EMPLOYEES DURING THE v4__ TERM OF THIS BOND? INTERNAL CONTROLS: I. ARE BANK ACCOUNTS RECONCILED AT LEAST MONTHLY? YES S( NO 2. IS THE PERSON WHO RECONCILES PROHIBITED FROM MAINTAINING BANK ACCOUNT RECORDS? YES 1 NO 3. ARE ALL PERSONS HAVING AUTHORITY TO MAKE BANK DEPOSITS OR WITHDRAWALS. PROHIBITED FROM EITHER MAINTAINING RECORDS OR RECONCILING THE BANK ACCOUNT? YES X NO 4. IS COUNTERSIGNATURE OF ALL CHECKS REQUIRED? YES .y NO ADDITIONAL COMMENTS: • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 020°—S CLASSIFICATION OF EMPLOYEES BY DUTIES OR RESPONSIBILi I1ES Th ossification 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 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,tune 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 A'OF OCCUPANTS �/ FA.#sc-+C i�;a-evfor f{ccocc"1-4 F` .'m;»i sir •r c. ! �o 'c :111 ' ' 3N c • OPF: t P 4 i AlrAgg 4 1 t;dcn4.i/,nefri a/s A/ Total Class A I`7f CLASS B EMPLOYEES All personnel whose principal duties consist of: 1. Inside or outside clerical activities; Office work such as stenography,typing,filing,switchboard operation,business machine operation etc.; Operation of vehicles transporting passengers for cash fare or tickets. POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS P6 1 r i CK Total Class B I 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 b`c t 4) id-C r g' OCCUPANTS • LL61 r tams.-k c E--wyloy.eYs 54,4SlQ Pr,J t—.'milli -e•c I Total Class C I 1 LMCITAPP.PEB(11197) PAGE 2 OF 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST CLASSIFICATION OF EMPLOYEES I3Y DUTIES OR RESPONSIBILITEES 5 ,2° This classification under Class A, B and C constitutes the cities personnel as of the date of this application and should include Mayc Council members. CLASS A LOYEES - A All Executive Administrative judicial and Supervisory officials.Department and Division Heads and Asstsrant Department and Division Heads. AU Police Office: all officials and employees whose principal duties require mhern ter I.) Handle,receipt for,or have custody of money,checks or securities,or account for 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 aver or deliv money,securities,supplies or other property,or serve process,or, 2.) Maintain or audit accounts of money,checks„securities.time records,supplies cc other property,or take physical inventories of money,checks,seem supplies or other property. +Patrolmen arc classified as"A'Employees under'Faithful Performance'Coverage but are classified as'C'Employees under'Dishonesty`Coverage. POSITION I OF OCCUPANTS POSITION I OF OCCUPANTS POSITION I OF OCCUPAN' cL'.r 7 Al n'3 y r+,.n e r e I fl t r, 1 ii'. r,cG Or'.ercrcr vv.c..t.,I `f r-•-• ►gfcw,vr*r«tir 0y149.r Jar 4-04.4•••• f3d.,14in1 struts/A.ihu3T;wu" I . �I.l.w1�m�eti+rF+t�t 9P[.. t'o1,-tt Clap' _ C ( bp. 1,rerles A,1^ec7� i Total Class A 13 • CLASS B EMPLOYEES All personnel whose principal duties consist of: 1. Inside or outside clerical activitiesti 2.• Office work such as stenography,typing.Ming.switchboard operation,business machine operation etc.; 3. Operation.of vehicles transporting passengers for cash fare or deltas. POSITION I OF OCCUPANTS POSITION I OF OCCUPANTS POSITION I OF OCCUPANT See.3:+m,t•t'/t.oc46dv-r 1 , irtQ 0,3pkx GcY"r cos/A/C0 l • Total Class B CLASS C EMPLOYEES All personnel whose principal duties consist of: I. Skilled or unskilled labor mid craftsmanship; 4. Any teaching capacity io the field of education; I 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 4. Patrolmen under the'Dishonesty'Coverage. f'o!iOSITION. I OF OCCUPANTS POSITION ft OF OCCUPANTS POSITION I OF • OCCUPANE --r Total Class C��^ j� LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 00, BOILER AND MACHINERY APPLICATION S' 1 _ ADMINISTERED BY: BERKLEY RISK ADMINISTRATORS COMPANY,LLC ' 145 University Avenue West St.Paul,MN 55103-2044 APPLICANT: I' 1 '1' o?-- O ccK Par/ >'C 11-4" / s INSPECTION CONTACT AT CITY: Lrl'� A. d vt- TELEPHONE#: 45/-e-A-3 AGENT'S NAME: Ln d/1ar,k �r1s - frir.7`�c 77/0/01.f, TELEPHONE# r1`4 n ,4-/n COMPREHENSIVE (INCLUDING PRODUCTION MACHINES) NON-REFERRAL OCCUPANCIES ONLY LIMITS: $ 5,000,000 Per Any"One Accident"Combined Property Damage,Business Interruption and Extra Expense $ 25,000 Expediting Expenses $ 25,000 Ammonia Contamination • $ 25,000 Water Damage $ 50,000 Ice Rink Buried Piping 1. Does the applicant currently have Boiler&Machinery coverage? Yes X 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? X Yes No If yes,please provide description and amount: 2o0 a- r R 170. 00 V.001 — Fuoncre. 'c. - a7o.00 2e'c,o - Air eandr'' -1'0K.er o,�� 1 rs - 12r/4717-co 4. 100%Replacement Cost Values of Building,Municipal Personal Property,Personal Property of Others: $ 7 * 5 L rn c ,T ftror-e-r y v�cfi tatu /,c 5. Non-Referral Occupancies Deductible: $ *Dr,...not include values for referral. LMCITAPP.BOILER(11197)(REV. 11199) PAGE 1 OF 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST REFERRAL OCCUPANCIES(Limited Coverage) Important: If the applicant has an exposure to any of the following,further analysis may be required by LMCIT. A representative of Hartford Steam Boiler(the reinsurer of LMCIT)may contact you for further information or inspection appointment. Each exposure must indicate a yes or no response. Special conditions,endorsements,limits and deductibles may apply per occupancy. *B *MPP *PPO *BI A. Refuse burning facility(boiler garbage burning systems-HBB) +Yes ' No B. Diesel electrical generating equipment(boiler diesel utility-HBD) _Yes X No _ C. Electrical generating equipment(boiler electrical production a Yes )X No utilities-HBE) D. Co-generation facility(boiler co-generation facilities-HBF) Yes No (*Does not include emergency back-up generators that serve only a single building or function and are not part of a municipal utility.) E. Equipment for recovering methane or other gases from a sewage treatment plant or landfill,or any other system for producing industrial gases(boiler industry gas production-HBG) Yes x No ._ — —F. Hospital/Clinic equipment listed below(boiler hospital-HBH) Yes No _ 1. CT Scanner Yes No 2. MRI Unit ^Yes _No 3. PET Yes No 4. Linear Accelerator +Yes _No 5. Lithotripter y Yes —No G. Steam or hot water district heating system(boiler municipal steam hot water-HBM) Yes ,X No H. *100%Replacement Cost Values of Buildings,Municipal Personal Property,Personal Property of Others and 100% of Business Interruption Values. NO"—'Coverage for the above referral occupancies can not be bound unless approved by LMCIT. LMCITAPP.BOILER(11/97)(REV. 11/99) PAGE 2 OF 2 AUG-09-2062 08:89 LEAGUE OF MN CITIES 612 281 1298 P.03/08 LEAGUE OF MINNESOTA CITIES Equipment Breakdown Coverage Proposal for: City of Oak Park Heights This is a proposal only. Coverage is not bound mall you receive a confirmation in writing from L411C17: Coverage(s)quoted are: 1. Comprehensive(Including Production Machines) Limits: $6.337,231 Per Accident-Property Damage '$5,000,000 Per Accident-Loss of Revenue and Extra Expense ' Subiimits: - JOa000-Service Interruption -•-- $ 100,000 Perishable Goods $ 100,000 Data Restoration $ 104000 Demolition and ICC $ 100,000 Expediting Expenses S 100,000 Pollutants $ 100,000 CFC Refrigerants $ 50,000 Ice Rink Buried Piping Deductible$ 500 Any one Accident IL Limitation of Coverage for Specified Locations or Objects Location Occiparicv KATE TIPPING SEP 2 3 2002 COF'IES TO:INSURED f EL Excluded Equipment OTHER( j Excluded t auiputent Location Occui ancv Annual Premium: $1350 Date: 84-02 Underwriter: Patricia M.Mingee `13gr O5? LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • • BOILER AND MACHINERY APPLICATION /137 ADMINISTERED U/ ADMINISTERED BY: BERKLEY RISK ADMINISTRATORS COMPANY, LLC • !!! 145 University Avenue West // /�j ��� St.Paul,MN 55103-2044 ( L...044 G C S e w r APPLICANT: . 04* u C u r c INSPECTION CONTACT AT CITY: kivn L-i- 1 C- rri r TELEPHONE 4:, fi S/-y3 9 AGENT'S NAME: L4 n dy14(k ri3r1 h II4.• TELEPHONE# 7`/10PI,A,IG-- COMPREHENSIVVE(INCLUDING PRODUCTION MACHINES) NON-REFERRAL OCCUPANCIES ONLY LIMITS: $ 5,000,000 Per Any"One Accident"Combined Property Damage,Business Interruption and Extra Expense $ 25,000 Expediting Expenses • $ 25,000 Ammonia Contamination $ 25,000 Water Damage $ 50,000 Ice Rink Buried Piping 1. Does the applicant currently have Boiler&Machinery coverage? • Yes No 2. • Name of current Boiler&Machinery carrier Expiration Date: 3. llas the applicant had any boiler and machinery breakdowns in the past 3 years? X Yes No If yes,please provide description and amount: -um 2 - rr a d-� r .. /7c)•c.2 0C,21 • 1 r 0,t ir�7..1 to r-zp ), 197.O 7 4. 100%Replacement Cost Values of Building,Municipal Personal Pro erty, Personal Propertyof Others: $ G 757 ay3 Z * )C .T ,-.� �..� -rf _.•�: ':"„) ' � r 5. Non-Referral Occupancies Deductible: $ * ..oes not include values for referral. IMCITAPP.BOILER(11197)(REV. 11/99) PAGE 1 OF 2 I LEAGUE OF MINNESOTA CITIES INSURANCE TRUST REFERRAL OCCUPANCIES(Limited Coverage) Important: If the applicant has an exposure to any of the following,further analysis may be required by LMCIT. A representative of Hartford Steam Boiler(the reinsurer of LMCII)may contact you for further information or inspection appointment. Each exposure must indicate a yes or no response. Special conditions,endorsements,limits and deductibles may apply per occupancy. *B *NAP on A. Refuse burning facility(boiler garbage burning systems-HBB) _Yes X No B. Diesel electrical generating equipment(boiler diesel utility-HBD) Yes �( No C. Electrical generating equipment(boiler electrical production —Yes No utilities-HBE) . D. Co-generation facility(boiler co-generation facilities-IMF) — Yes -ex-No (*Does not include emergency back-up generators that serve only a single building or function and are not part of a municipal utility.) E. Equipment for recovering methane or other gases from a sewage treatment plant or landfill,or any other system for producing industrial gases(boiler industry gas production-HBG) Yes No F. Hospital/Clinic equipment listed below(boiler hospital-HBH) Yes X No - _, I, CT Scanner Yes No 2. MRI Unit _~Yes No 3. PET Yes No 4. Linear Accelerator _—Yes _No S. Lithotripter Yes No G. Steam or hot water district heating system(boiler municipal steam hot water-HBM) Yes No H. *100%Replacement Cost Values of Buildings,Municipal Personal Property,Personal Property of Others and 100% of Business Interruption Values. NOTE:Coverage for the above referral occupancies can not be bound unless approved by LMCIT. :1TAPP.BOILBR(11/97)(122V.11/99) PAGE 2 OF 2 1 S LEAGUE OF MINNESOTA CITIES INSURANCE TRUST EXCESS LIABILITY APPLICATION Administered By: BERKLEY RISK ADMINISTRATORS COMPANY,LLC 145 University Avenue West St.Paul,MN 55103 (651)281-11200 City of (3 4- P" ' Q ..c.. 4- Date to - I 1 V n 3 Limit of excess coverage desired: $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 Do you want the 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 liability. Do you want the excess to apply to liquor liability? Yes ),( No Special Note: The liquor liability primary limits must be$1,000,000. Emp,.1ers Liability: Carrier: CAC l T Limits: t 000 e OC O • Policy Number: Policy Period: 1-1— 03/0 Does applicant now have or contemplate any exposure under: (If yes,attach sheet with payroll figures.) (a) Jones Act or Admiralty Jurisdiction Yes No (b) Federal Railroad Employees Act Yes k No (c) Federal Longshoremen's&Harbor Workers Act Yes No To what extent does applicant have primary insurance to cover these exposures? . . (04., IF THIS IS A RENEWAL,PLEASE INDICATE IF RENEWAL IS TO BE BOUND: " • X YES NO Note: Coverage is excess of LMCIT coverages only. Some of the coverage is not follow form. LMCITAPP.12(11/97XREV.11/99) PAGE 1 OF 1 • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST ADMINISTERED BY: BERKLEY RISK ADMINISTRATORS COMPANY,LLC 145 University Avenue West St.Paul,MN 55103-2044 SUBMIT 1 ED BY: La w (c ( h cJ uzc�J PRODUCER: ( e t ADDRESS: 0332.. Lam. 5.4- • S. Furl Lc., Alev ' sO V5 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 I. Name of city or other public entity whose city officials are to be covered under the Agreement. et 47 rtle nal PPC14(4- i4 44:00 lY 2. Principal Address: 14 (42 g 90.4.fc 1yeJ G eatN (c. -a.,.L tMA .) 550S-2 ~(A7 3. If Joint Powers entity,identify participants: LMCITAPP.OML(11/97)(REV. 11/99) 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 ears.. For each incident give its approximate date and its resolution, including the penalty Y PP imposed, if any,and the amount of attorneys fees incurred in def e nding the incident. ident. • y 4' ""1 `✓i �.h ? � 3A'V y• ! /$`'r, +,/�'F�ryf tV! "�•''� Y/1C '/ .PL d '' ' .. �j'i'Y�'` r < r F Cf .�ria t '✓ f 5k.ic r ,rv� *c$, y f� r ci 'sac hs ° s b�1 t" 7 a s e a � �w$a a w N as o a t5�' a2r X,,r "f+r^r�s^b l < c, c >�*' 6Y ,yA.rnm.. � ;<,"y, R �d'�c a tb,t >'( Y ^" ` v"��, ,b4. i y'k >� ,roe, !4 24. I w M../ • 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 y NO If YES,give details: 3. What action has been taken to prevent future incidents or claims? LMCITAPP.OML(11/97)(REV. 11/99) 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: cto 2. Have all new members attended the League Conference for Newly Elected Officials? }C 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, ...): . sue. 044 uw 5. Does legal council attend all official meetings? )(I 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: k YES NO 7. Please indicate the percentage of reimbursement of defense costs. 80% 100% X BY: (Signature and Title of Authorized Representative) LMCrrAPP.OML(11197)(REV. 11-99) PAGE 3 OF 3 i is , , `, t , 2.- p a 4 p !S -dz , i t}t 6 lee'a-e-- , /g ()go P-t-ii/,J...--e. _ Sz.s... 54.0,, _ , _ , , , a 7/ , .-6z-z) & 451,Z. _ .1...,<___ ,76,6, r7e2 me ts- ,. A7, /17- 6 4,,,,t--..ex, V-4.r.,4,7 a...... ..„ . , ; 5, 75'0 t -1.-Q-e. oa.c. gt{7/ _) o i' //534.., 9/ / , .t t 1 yl, , !. 0 �Dr Administration Salaries �0 J J Estimate for 2003 3c.t. Administrator Base Salary (4-15 to 10-15) 35,925.00 2003 Est. 51,373.33 101-40400 Base with 4% Incentive (10-16 to 12-31) 15,448.33 51,373.33 Judy H. Additional for Acting Admn 2003 Est. 8,489.81 101-40400 (1-1-03 to 4-15-03) 8,489.81 Julie J. 2003 Union Contract 40,824.00 Ann. Sal. 41,232.24 1% Incentive 408.24 Comp Time 792.93 2003 Salary 41,232.24 2003 Est. 42,025.17 101-40400 Hourly Rate 19.82 OT Rate 29.73 40 hours comp time @$19.82 792.93 Total Administration 101,888.31 PERA 2,793.48 FICA 7,794.46 5.18% 2,616.68 117,613.58 Dif. 176.80 ICMA 5,137.33 Temporary Employee as needed, 20 hours per week.. Paid 1-1-03 thru 5-4-03 5,972.08 Due 5-5-03 thru 5-11-03 43.75 hours 17.85 per hour 780.94 Total Temp Employee 6,753.02 Total Administration including PERA and FICA 124,366.60 2003 2003 Budget Budget Estimate Adjustment Salaries of Regular Employees 124,030.00 101,888.31 22,141.69 PERA Contribution 6,860.00 7,930.81 (1,070.81) FICA Contribution 9,500.00 7,794.46 1,705.54 Salaries of Temporary Employees 6,815.00 6,753.02 61.98 Totals 147,205.00 124,366.60 22,838.40 a Community Development Salaries Estimate for 2003 Jim 2003 Union Contract 59,208.00 Ann. Sal. 63,352.56 7% Incentive 4,144.56 Comp Time 1,218.32 2003 Salary 63,352.56 Overtime 0.00 Hourly Rate 30.46 2003 Est. 64,570.88 101-41530 OT Rate 45.69 40 hours comp time @ 30.46/hr. 1,218.32 Julie 2003 Union Contract 40,824.00 Ann. Sal. 44,498.16 9% Incentive 3,674.16 Comp Time 856.00 2003 Salary 44,498.16 2003 Est. 45,354.16 Hourly Rate 21.40 OT Rate 32.10 40 hours comp time @ 21.40/hr. 856.00 35% 15,873.96 101-41530 35% 15,873.96 101-41200 2.50% 1,133.85 101-42010 15% 6,803.12 101-44010 5% 2,267.71 702-48100 5% 2,267.71 702-48200 2.50% 1,133.85 702-48300 45,354.16 Total 5.18% 5.53% Total Community Development 15,873.96 PERA 822.27 877.83 FICA 1,214.36 Total Building Inspection 80,444.83 PERA 4,167.04 4,448.60 FICA 6,154.03 Total Streets 1,133.85 PERA 58.73 62.70 FICA 86.74 Total Parks 6,803.12 PERA 352.40 376.21 FICA 520.44 Total Water 2,267.71 PERA 117.47 125.40 FICA 173.48 Total Sewer 2,267.71 PERA 117.47 125.40 FICA 173.48 Total Storm Sewer 1,133.85 PERA 58.73 62.70 FICA 86.74 Grand Total 109,925.04 PERA 5,694.12 6,078.91 FICA 8,409.27 109,925.04 PERA Dif 384.79 2003 2003 Budget CD Budget CD Estimate Adjustment Salaries of Regular Employees 92,815.00 15,873.96 76,941.04 PERA Contribution 5,135.00 822.27 4,312.73 FICA Contribution 7,100.00 1,214.36 5,885.64 Totals 105,050.00 17,910.58 87,139.42 l M CO H m CO CO O O 0 0 0 0 00 N 0 0 O O 0 0 H H N O W S N o 0 0 0 N N \ El H H O O 0 0 s• V 0 l0 t0 co CO CO CO t0 t0 01 cn CA 0 V t0 0 M M 0 W U co 0 0 A,' al O O cn al W O O O 0 N N , N N N N 0 0 .-I r-I a' 4-) N N U) •rl 0 A N al 0 al AU Cu .0 0 0 OD CCO 0 C) .l) N t I-- . . . 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Ln (`') o') Co Co H H 0 0 H H v' a' (N N (") OD H H N N l0 ■0 ^7' v' H H .ri 0 s cr m r1 H H 0 N N N U Cu zs '0 -cs •d -0 zs Ti -o v u '0 '0 0 o o 0 0 0 0 0 0 0 0 0 0 0 0 1-I 0 1-1 0 S-1 0 1•I Eo 1-I C] 1a 0 S 0 i.r 0 1a 0 1- 0 1-1 0 .4 0 1a 0 a >, a >, a a /� a a H a ✓ a H a r, D HH'1 0 H a 1 04 H o 0 0 0 0 0 0 U U H U U U H H H Z Z a - m 0 rx Z Z Z a Z 2 di W H H Z Z Z CO < f Z 0 a U < a g F g Z • X EEl E-■ 0 E1 Z a H 0 H H H U H H 0 < • a Z W C7 3 I x v) a a a 3 W W W Z at Z a g x W W W W x x Z H (n 0 W x x x Z H H I w 2 0 0 w w o 0 o s a C I I a 0 a Z a H a a a a a H .r1 I-I H C) (ii 0 <, C) C) C) C) H H H Fl, Z Z p+ U U H U U Z Z Z G W W W E1 H x x a rx a W W W W •■ 0 0 a W W W W W 0 0 o � CO CD CO H (11 W W H 0 0 0 0 W W H 04 i CO O U U U U 0: CO W a Cu 04 's LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 145 University Avenue West St. Paul, NV 55103 (651) 281-1200 APPLICATION FOR THE CITY OF: 00k Pea k- (4.-1 A- nn County: (L 2„,tk cV\ Mailing Address: , ( 1 ( (� d P�( 13 NJ • Phone:, 66I"L34 " 39 City, State, Zip: O %AI cc ffaittica ! 09N S 5o&2 " (7c' City Contact: ()Wilt / 11 G Title: C;Qin ^r'iirve4A Apott `•' Ir 1990 Census Population: 3 Lifg(P Current Estimated Population: Y19/ Foe o asi?S _ � 3857 Total Expenditures All Operations: 62, 1 d 6' /, s _ i a 2 >: Is the City a Member of The League of Minnesota Cities? X Yes No // 7-q/ . t !J+ Submitting Agency: 1 -�`4p'""`ou/ IN St-t�V Ct."CJ a , ,2 ad Address: 2 3 2. Lac - £ So City, State, Zip: (;)/.v —cJ�-. £ Ai S502,5 Telephone: ((o SI) t1 Co(( 3 3 3 3 Facsimile: ( 4) t ) 14(0( ' ?5ci fP Agency Contact: i y e + n y Date of Council Resolution or Contract Appointing the Agency: AGENT COMPENSATION: X 10% City Will Compensate the Agent Directly Other Please specify: Standard Deductible: SS 00 • (Applies to All Lines. Optional All Lines Deductibles are Available.) Current Information on Coverage You Are Applying For: Carrier Policy Type Expiration Date Premium mc o- P tc.06 7-1-0 3 wc'OW>I frt.(5 B LMCITAPP.TBL(11/97)(REV. 11/00) PAGE 1 OF 19 t LEAGUE OF MINNESOTA CITIES INSURANCE TRUST Y PROPERTY/MOBILE PROPERTY COVERAGE ''i ��� �✓ Blanket Limit of Coverage Per Occurrence to be established by LMCIT. a- f This limit is established by totaling the replacement cost values of all your buildings/contents, property in the open and mobile property. 1. Bu, • BUILDINGS/CONTENTS/PROPERTY IN THE OPEN 2• a"%`°)1•3 Con40w13 3. P.-0 rr-t.,1 ,r `tt d� d79' Attach updated schedule of buildings/contents,and property in the open. Ut Ii'c Ins c Prr>4! MOBILE PROPERTY- GREATER THAN $25,000 Attach updated schedule of mobile property with replacement cost values greater than$25,000. MOBILE PROPERTY-$25,000 OR LESS Mobile property with replacement cost values o 'r 'it less can be covered with no schedule. There is a flat premium charge. Do you want this coverage?(YES [ ]NO 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.30(11/97)(REV. 11/00) PAGE 2 OF 19 , LEAGUE OF MINNESOTA CITIES INSURANCE TRUST WATER AND SUPPLEMENTAL FLOOD COVERAGE APPLICATION l. Does your city have any locations in a flood hazard area? (/1A 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 maximum amount of insurance available for the LMCIT Supplemental Flood Coverage to be available. Please contact your Underwriter for further information. ,w �"� n3 a t v� a �i nti'h � I i ) 2 . 1jPfi �°qFr� Rc 9 "r1�e� �ati ���R41 i�oa�t��y �� Inoi�l �� �! 71 4.i • LMCIT.APP(11/OO) Page 2a of 19 • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PROPERTY The covenant provides Errors and Omissions coverage for Property. The following information is needed to designate the entities that are to be covered. Please indicate if you want the following entities to have coverage for Property Coverage. • !Jim(?) slsriF f • HOSPITALS YES NO N/A_k NURSING HOME YES NO N/A HEALTH CLINICS YES NO_ N/A AIRPORTS YES NO_ N/A ELECTRIC UTILITY YES NO— N/A GAS UTILITY YES NO_ N/A 1 STEAM UTILITY YES NO N/A HRA YES NO X N/A EDA YES X NO_ N/A PORT AUTHORITY YES NO_ N/A ADDITIONAL INFORMATION: LMCITAPP.11(11/97)(REV. 11/00) PAGE 3 OF 19 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 d l (s• $ o Debt Service Enterprise Fund 7 49 5 6/0 Port Authority Special Revenue Funds -7 a 0-0 Nursing Homes 0 Capital Improvement Funds 7 7 7 // Hospitals O Airports Clinics HRA °* Other(please describe) Q EDA -, Line II Transfers 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 Adjusted total expenditures is the total expenditures for those departments and operations that have E&0 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 Service(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. PL's SE ATTACH A COPY OF THE LATEST CPA AUDIT AND/OR THE PROJECTED BUDGET(WHICHEVER REFLECTS THE EX. ..QDITURES ON THE WORKSHEET). THIS INFORMATION WILL ASSIST UNDERWRITING IN ANSWERING ANY QUESTIONS WITH REGARD TO THE EXPENDITURES WORKSHEET. LMCITAPP.13(11/97)(REV. 11/00) PAGE 4 OF 19 LIMIT EXPENDITURES WORKSHEET _ City Oo @ay((,,, 4,10 Budget Year C 0 All Expenditures I / 3S I 7 Transfers ,2 6,Er ps III. . E&0 Deductions a) HRA b) EDA c) Port Authority d) Nursing Homes e) Hospitals 0 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) V. GL Deductions • a) Contracted Services f S:360./ • b) Debt Service 0 90 S"$/ c) Water Department Only .233 ,d S d) Electric e) Steam f) Gas g) Liquor(Operating Expenses Only -Do Not Include cost of goods sold) h) R ecreation Buildings(Arenas,Sr.Citizens Centers,Ic e Arenas) nas ) i) Swimming Pools j) Golf Courses k) Individual Purchases which exceed 5%of the adjusted total expenditures(E&0)(List&Describe) [) 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) 2, J O S /1.‹. LMCITAPP.11(11/97)(REV. 11/00) PAGE 5 OF 19 LEAGUE OF MINNESOTA Cl'1'1.ES INSURANCE TRUST MUNICIPAL LIABILITY-SEPARATELY RATED EXPOSURES DO NOT LEAVE ANY SPACES BLANK IF NO EXPOSURE PLEASE INDICATE N/A OR NONE City of ()G - Poo t4--24.0 n-' Date Co — 11— 0"I- I. Golf course annual receipts: 1A.OvA.. Number of golf carts: tkriln2 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, Auditoriums or Community Centers: y►. 4. Water Department payroll: /D Z t F ; `,°�V V 1 .�y` f1a • Total gallons of water pumped annually: goo e • (Round to nearest million, i.e. 2,500,000 should be 3,000,000) 5. Electric Department payroll: ln.c4A.. 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.01(11/97)(REV. 11/00) PAGE 6 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 10. Municipal liquor store receipts: Kieu 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: • Height: Length: Location: Seasonal: Year Round: 15. Does the pool(s) comply with the Minnesota Dep nt of Health revised Chapter 4717,Public Swimming Pool Rules effective January 4, 1995,cone ruing water depth requirements for diving boards and pool decks? Yes No 16. Number of staff attorneys: Do you want coverage to be excluded? Yes No Additional Information May Be Necessary 17. Does the City want to exclude medical payments? Yes No A LMCITAPP.01 (11/97)(REV. 11/00) PAGE 7 OF 19 LEAGUE OF MINNESOTA Cl'i'LES INSURANCE TRUST MUNICIPALITY QUESTIONNAIRE DO NOT LEAVE ANY SPACES BLANK IF NO EXPOSURE PLEASE INDICATE N/A OR NONE City of 04'94' ?cos (L (-14:‘1(°%5 n— Date Cy— 1 l -- 3 1. Does the city own or operate any of the following? �.,.n, � t_ri i` ril r 1 r 1 rf �lj r5{ I yr Il C, t 1 ,. t } t I �JI I d3�'c � 4 I r I 1'Y#t � ,h I'. >,,'h i Y(1rt,F�I ' t 1 1 I, EaI If���k��tl y� a ,�' I 1 a lil�i�g 1 ��, . _ + i; �Pr., I I,i halt III 1^'c ? Rxr fllY a �ih+X, d ICIA:410 1af E}k f�'. S} ° ��f.�1'l'},ita Satlsl VI � �t (:AI Ail s r ., , 1 i r.: .,i f ' ' i a 4. 4 f �C i(7s�tYl���tks 11 C�o�2�C 9o� aP r e YOY 41' dIiK :'1+� ,5� 9tKt '44, P �s t t3tt 1 (Jo.�s j 55 ��ts Y 1 i7 j I t y r' .y}�` r4t ,,.1 'F b�yaa A(w, ` 1y ti �I1 l' e c 3 I r , a i t !-. ,xa ,f '�L1 I`'V.t! B.�I t :�-,U�1r°}4�1C:: .F,{ t 1 -;, -i f .1j..f1 a� !!¢ 2,A �rl.�f41d � I:I �E, i -n-1 .A. I{ y., rrtru4 Y Ire , eY {} ,} I N i-: r r �w J { ylt i_1 �� �e a .af i it t x-, r w+ J{ d ' 1(r � i lh1 v i i �4 A _.�.,,,.. ' y dt'�.-�..,a�*lat.•:t,:..�ur.L...s.t�k:}i 5....>._�s�."a��..�..- ri�,_�,r:.� ,._ ,�l :. __ �..s�.�__..._.__,�..�t�: ,s..._�l�',......,.��s� >���.,_....___.s.t�.._..._5.�� Hospitals Yes X No _Yes No Nu. ..g _Yes "K.No __Yes No Homes Health Yes `".No Yes No Clinics Airports _Yes K No Yes No Comments: * Municipal Liability, except for bodily injury property damage or personal injury, is automatically provided for the City 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 City and the other Governmental Body or Entity. PAGE 8 OF 19 LMC1TAPP.02(11/97)(REV. 11/00) 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 P e 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 J}d,'ha a,s},.i,,Ii l 4.tiitI�.l^;-u�.;t_i!�6 -I a IA` ,"t!✓+fi..._s sr.)a ua n�v.=t u1 �_.e�i i�-.+*B`1.t.a`L�d`� t I sf.11 -''aly lJ..-..L z a 7 f i`t IyCaf!i I, 7-r 4 ." T.d" f� F p�yM y kftf+P Y S ; i t 7 3y—g'�sgg i-b''6.�.i.-i,➢'a.=..2 t 10 IJA a (,,,y±- v 1 €i 3 i t 1 )x 4 t 7 11' ' i11- !LNkfi l `-- Gas Utilities Commission _Yes No Questionnaire Needed Electric Utilities Commission _Yes SI No Questionnaire Needed Steam Utilities Commission _Yes No Questionnaire Needed Port Authority Yes 1!� No Need Full Details Housing&Redevelopment Authority Yes X No Need Full Details.— Economic Development Authority X Yes -No I/ ?00- OD Need Full Details Area or Municipal Redevelopment Yes r No Need Full Details Authority ty Municipal Power Agency Yes No _■ Need Full Details Municipal Gas Agency Yes No Need Full Details E A- :.CC / S hCLs5 C:.+-42ft i # LMCITAPP.02(11/97)(REV. 11/00) PAGE 9 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 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? Y I 1 C. { F — v , .J r it• h I2�, 19$41 i. . 111 rT t 4iT ¢ 1 j• 7 P 5tP Ilk, o}a r e! u• 1_T•' ! . •C . « . A ' ! 11•,0� 4h t 0 �a�f'�0 �R i'a y -4A1.4"4.:fi i 1.01-4 7.-• c1 Welfare or Public Relief Yes No Need Full Details Agency School Board _Yes No Need Full Details 4. Does the city operate a dump or landfill? What type of material is deposited there? Is the area fenced to keep out the public when closed? 'c the area attended during open hours? 5. Does the city own or operate a marina? r If operated by others, please indicate and advise if the city 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.02(11/97)(REV. 11/00) PAGE 10 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 11\-(a" 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.) A. Age of Dams: Inspected regularly: Yes No 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: 7. Describe any large construction projects anticipated for this coming year. c.c.a_r--L- ti in - --7-71•01 4-fe koS . s> ot07JWu/LS r.1/7 n/ior%vo brio 4 n sAta 47o/ore x.in,r.��� /.S.7 /i v✓K , u,1/fs A-11 e.l e2 p-e.r pc,,,,` 4, 8. Parks and Playgrounds A. Description (including area) of each park or playground: te^ -e- s 11,Cs ■ B. Description of playground equipment on each: c n�v LMCITAPP.02(11/97)(REV. 11/00 PAGE 11 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST • 9. Does the city 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 city own, operate or sponsor any of the following? If yes, pleaseprovide 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, madder courses, tractor pulls. (Excluded) Yes No B. Amusement devices, with a power motor greater than 5 H.P (Excluded) Yes No C. Beer booths (Liquor Liability is excluded. Refer for consideration) Yes No D. BMX tracks Yes No E. Climbing Wall Yes No F. Dunk Tanks Yes No G. Festivals, parades and exhibitions Yes No H. Fireworks (Excluded. Refer for consideration.) Yes No I. Rodeos (Excluded) Yes No J. Skateboard Parks Yes No K. Ski jumps, ski lifts and tow ropes Yes No L. Toboggan or Tubing Slides Yes No M. Trampolines Yes No If any of the above are operated by others, please advise if the city is named as an additional insured and the lolicy limits provided. (Continued next page) LMCITAPP.02(11/97)(REV. 11/00 PAGE 12 OF 19 LEAGUE OF MINNESOTA CIIIES INSURANCE TRUST 10. Special Events/Risks (continued) Details: 11. Firefighters cravat,.�!. iv; rvtc.A. thin- C; c' g •,v1- Payroll of paid firefighters: '"Cit"A' Number of volunteers: Number of fire trucks: vs.O■A.R., Describe any fund raising activities or celebrations by the firefighters or relief associations: 12. EMT's and Paramedics "fa. 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.02(11/97)(REV. 11/00) PAGE 13 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 13. Law Enforcement Total law enforcement payroll: G6 ?, 700 4/ ./(j j Number of law enforcement vehicles: Number of Employees by class: Class A(Full-time): A (Part-Time): 0 Class B: Class C: 0 Class D: Class E: 0 Class F: 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: 1'» Describe any jail or detention facilities maintained: ( u.-e- Co(.,4. C: 4�. Maximum holding period: 04 CaritiP lrx,� k .) 14. Grandstands and Stadiums A. Number and location of each: 1 1 '42.4(c . ePa-v' CZ- C ( ^r"'' QA--4- beCitalot.0 B. Seating capacity: (q d C. Type of construction: •Q�.2d2 qr D. Permanent or temporary: lug �nna.,•�.15. Wharf or Docks -Describe: Y\Cv-t. LMCITAPP.02(11/97)(REV. 11/00) PAGE 14 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 16. Street or Road Construction or Maintenance Annual expenditures: ,1/ 7 . D© a- c ‘"'1 -6.a How much work is sublet to others? 414 5_4114/LA A..U GalrA- Are Certificates of Insurance obtained indicating adequate limits? Is any blasting done? ✓%3" 17. Please describe any contractual agreements the city has entered into such as: A. Mutual aid: (.f)c rC B. Police or fire protection: / 4 F C. Other. Describe: 18. Dint 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? 1Z1 20. Does the city provide a fire alarm or burglar alarm protection system? If so, please give full details. CI -e c t t.r..AS leAr �.tr�,c x 4 U. A,,,c9 C -v� Loc G c �r(c c.cnr i a2aNvv+. -LA tr +Ai-C (2.4.4-hrwtx^ris," 21. Any other pertinent information not covered above: LMCITAPP.02(11/97)(REV. 11/00) PAGE 15 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 22., City was created in: t 91 y (Year) 23. Names and official titles of the Members of the Board of the City: (City Council) Name Official a{ ecc.u.e(e t" c [rt Les /�brcc.harn Sort c - - -0 .Q. Nw +r' 50..ok -Poe rr cc t&ry inceaµh cr cc etr is S W.ensort I ' li 24. Fiscal Year *Revenue *Expenditure Fund Balance At Year End Projected Year 5,1/3/I Y/&3-c,/8-7 2 Z '/ Z !Za ,.9D 1-Z3 4OO Current Budget / ?°?tj° 7O Ap o I 1st Prior Actual zao 2q f, , `( 72� fo(( , CQ 16004 4AD$ • pOO 2nd Prior Actual y 7 q9 WS.*. ' 4152711°A(9 / 4, / WO 7749 . 19 q 3rd Prior Actual 5liggig?e• lox. ccsc• 4.1°57, l(pg . *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:. 2 2-7 0 000 -31-0 b. Latest Moody's and/or Standard and Poors' bond rating: A V. - frtoocQ4. LMCITAPP.02(11/97)(REV. 11/00) PAGE 16 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST Have any of the following situations occurred within the last five years? Yes No a. Appropriation or condemnation for which agreed settlements have not been achieved. b. Improper or alleged wrongful granting of variances, building permits or similar grants or zoning disputes. c. Wrongful or alleged wrongful approval of building plans, designs or specifications. d. Wrongful or alleged wrongful approval of building construction. _ x e. Allegation of unfair or improper treatment regarding employee hiring, remuneration, advancement or termination of employment. f. Disputes involving integration, segregation, discrimination or violation of civil rights. g. Any grand jury indictments of any public officials. h. Assault and battery claims made against the municipality or its officials. i. Any riot or civil commotion in the past five years. j. Any losses or claims occurred involving contractual disputes. �C 27. Land Use Liability Number of building permits issued: 2-I Number of variances: Granted (j Denied 0 Number of conditional use permits: Granted 1, Denied 28. Has the City.submitted their Comprehensive Plan to the Metropolitan Council for review and comment? Yes X No Has the Metropolitan Council reviewed the plan and made their comments? Yes.L No Are you a participant in the Metropolitan Council Livable Communities Program?Yes No What year did you join? !' 't Co LMCITAPP.02(11/97)(REV.11/00) PAGE 17 OF 19 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 29. Please list the additional covered parties required. h( U1 6 ( f r e V{ 0.112)V` .,'(3111 L1,1 r 0'-^ 1, itkr a 11 �� rd�a t fuz 61111 t, � bVr • � �� Viy�jLl � E1�cr1Q - l��(r�� �f ADDITIONAL COVERED NAME ADDRESS PARTIES INTEREST • 30. Contracts with a railroad and contracts with the contractor performing 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 project. LMCITAPP.02(11/97)(REV. 11/00) PAGE 18 OF 19 • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST AUTOMOBILE LIABILITY AND PHYSICAL DAMAGE CITY OF © ?ow- ,Q,�, 1. COVERAGES: A. Liability: Limit: $1,000,000. Combined Single Limit o n Bodily Injury Property Damage B. Uninsured and Underinsured Motorists (indicate limit desired) $50;000.Uninsured and Under insured Motorist Limit* or X $1,000,000. Uninsured and Under insured Motorist Limit *The standard limit is$50,000. The City may increase if they chose. C Automobile e:Physical Damage: l: The separate"comprehensive"and"collision"coverage options have been replaced by the new"auto physical damage" coverage that covers both collision and comprehensive. 2. Cities have the option to make their LMCIT Liability Coverage primary for vehicles used by specified individuals or groups in specified circumstances. Please indicate if you want this optional coverage and provide additional information requested Yes X No 1. ,please indicate type of individuals or groups: If yes,please indicate number of individuals: 3. VEHICLE SCHEDULE Refer to the LMCIT Auto Coverage Changes bulletin included in your renewal packet. The city needs to submit an accurate listing of vehicles for the renewal. The city's premium for auto liability and physical damage coverages for the entire year will be based on the schedule of vehicles the city reports at renewal. A. All vehicles are covered for liability. B. All vehicles are covered for physical damage,unless you indicate otherwise. C. The listing of vehicles should include only those trailers with a load capacity greater than 2000 pounds. Smaller trailers are now automatically covered for liability and physical damage. D. Replacement cost is available for an additional premium on Fire Trucks and other high valued vehicles aged 10 years or less. (Indicate unit number and replacement value). E. Replacement cost may be considered for an additional premium on units aged 10 years or more with proper documentation of the maintenance history. F. Please indicate color of Fire Trucks l=Lime Yellow;2=Red;3=A11 Others (The attached computer printout provides the most current Schedule. However, recent changes may not show on the Schedule.) k`ta� ¢TOIL:!�+ !r i� y ne r 4',. .7 !�t ;$ y9 r. ��' +„y�i r „ �!F i ,{ii fir- �i gp' t ru dip„ Frk ..(r a ,.y k� 1 4f `..;( IFIS 7 " _..]Q p� t� ; J 4 �, 't-A4 t.. �-1601-114,tF �({'^ �'''4' i`n t.tt•- Lii� �l 4 't l � :*;\704-641j7.'' r � ,4.0-";�h1`'14'4 ^{ �x 1�.� ! t y{j i6 t � �4 `' + lri. rs, �i ! .ly �, ! `(r .� !J V. �t t s__�. ^ L . to °� z ! ^ 'J.l. .r7 n-P tJ`..ta�,r a ! i + !i. (t f' r_ ;tr; '" ! -!: 4 ^P ;y 3f f a V 'mtft". F!� ,.e i i '�ti r a ! 1 �:„J,:,1,1 !. !! �r r tri; .C� �4Hle�r Yh x -;°lu ^ nS�, -,,. 7iN'^`i '.Ir'�J l fei y,� ,�+r,',�t i� .aty. �� N �� rwv i'..tom 2 fi^� 1� ,r,`.`$ X�A""�1' .� Y ^fig i, Y�ih P,, �. ' � fa earl. Y !� ud;}, �Ga.0 WLS �3 ,M..,,��r�..,, .0. 1 2 I3 LMCITAPP.15(I1/97)(REV. 11/00) PAGE 19 OF 19 • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PT- -IC EMPLOYEE DISHONESTY OR PUBLIC EMPLOYEE FAITHFUL PERFORMANCE COVERAGE APPLICATION ADMINISTERED BY: BERKLEY RISK ADMINISTRATORS COMPANY,LLC 145 University Avenue West St. Paul,MN 55103-2044 Limit of Coverage Per Occurrence: (Deductible) • Bond Employee Dishonesty Coverage: $ 1001 000 • (Standard) • Bond -Employee Faithful Performance Coverage: $ t 00(000 (Standard) • Option: The city may choose to have employee dishonesty or faithful performance coverage for specified positions. Please contact your LMCIT underwriter for additional information. X50/000 . (oast.WOO AUDITS: FREQUENCY: BY WHOM?: CPA X _ STAFF AUDITOR C '` OTHER(Explain Fully) DATE OF LAST AUDIT: DISCREPANCIES?: YES 1.?31-02., No (If YES submit copy of audit or auditors comments.) LOSS HISTORY(LAST 5 YEARS): EMPLOYEES POSITION WHICH CAUSED LOSS: CORRECTIVE MEASURES TAKEN: 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? YES u NO 2. IS THE PERSON WHO RECONCILES PROHIBITED FROM MAINTAINING BANK ACCOUNT RECORDS? YES NO 3. ARE ALL PERSONS HAVING AUTHORITY TO MAKE BANK DEPOSITS OR WITHDRAWALS. PROHIBITED FROM EITHER MAINTAINING RECORDS OR RECONCILING THE BANK ACCOUNT? YES k NO 4. IS COUNTERSIGNATURE OF ALL CHECKS REQUIRED? YES ,y NO ADDITIONAL COMMENTS: • LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 0200...3 CLASSIFICATION OF EMPLOYEES BY DUTIES OR RESPONSIBILITIES Th. assification 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 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 & Pita c-c r-erJtdr` [cticcn.ttc.ct. �- t • ' W.re ' 1 rr, O i Alre G / Courai/ 1 hers Total Class A /`7r - CLASS B EMPLOYEES All personnel whose principal duties consist of: 1. Inside or outside clerical activities; Office work such as stenography,typing,filing,switchboard operation,business machine operation etc.; Operation of vehicles transporting passengers for cash fare or tickets. POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS POSITION #OF / OCCUPANTS P61�CK r'6paidoer Total Class B I 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 /r`e Ci ct-C r OCCUPANT'S • fe l i i e.. W/1<s kr6e-S CJ0 4snne..( PIO 1 rn)t i*-eY • Total Class C 1 LMCITAPP.PEB(11/97) PAGE 2 OF 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST EXCESS LIABILITY APPLICATION Administered By: BERKLEY RISK ADMINISTRATORS COMPANY,LLC 145 University Avenue West St.Paul,MN 55103 (651)281-1200 City of 0 q,Q - P" t Q. 4,,c1 11- Date (o - ( 1 V 0 3 Limit of excess coverage desired: $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 Do you want the 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 liability. Do you want the excess to apply to liquor liability? Yes )( No Special Note: The liquor liability primary limits must be$1,000,000. Emp,..,ers Liability: Carrier: LMC. 1 T Limits: I t 000( 000 • Policy Number: Policy Period: 1-1— 0 3/01 Does applicant now have or contemplate any exposure under: (If yes,attach sheet with payroll figures.) (a) Jones Act or Admiralty Jurisdiction Yes .� No (b) Federal Railroad Employees Act Yes k No (c) Federal.Longshoremen's&Harbor Workers Act Yes No To what extent does applicant have primary insurance to cover these exposures? (04.. IF THIS IS A RENEWAL,PLEASE INDICATE IF RENEWAL IS TO BE BOUND: • X YES NO Note: Coverage is excess of LMCIT coverages only. Some of the coverage is not follow form. LMCITAPP.12(11/97)(REV. 11/99) PAGE 1 OF 1 LEAGUE OF M NNESOTA CITIES INSURANCE TRUST ADMINISTERED BY: BERKLEY RISK ADMINISTRATORS COMPANY,LLC 145 University Avenue West St.Paul,MN 55103-2044 SUBMTr1 ED BY: LG "`°t (14-- 1 h% adveA PRODUCER: 1LCt,t ADDRESS: ?32. GetS•e. 5.4- • • U F04.44 A-- C.�Qc-�. Al"/ p z5 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. C aGcr 'Paw(4_ i4.e4:00 • 2. Principal Address: 1'4 142 g 0)1c...9,3.4, re. i).Q . G' Pow lc. 4, 4 044Ai S5OS —(0 3. If Joint Powers entity,identify participants: LMCITAPP.OML(11/97)(REV. 11/99) PAGE 1 OF 3 i 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. ,,,t Z r, , fiq�Y.1f,�iuu n s�,s t d`�a x c.�xi1..Gti�av,).:'�`r��h r y w,5 tx�aYt'<.x2�..�._t}f%,zF,,�.Y• �,,• <• ay,�,�.'.i±Zay'ha,�.'*,^'.,f,whx�t,}�.s...�.s�'�`wc 3i:`k��.s'xu.'�';�,;• '?�• '2Y"'*c"c�,��`o-,�^cy'o o r{',"..y r...'.�`.F.r.r``{2r',cP�++a t t r.., hl'�.,.x*':�. ;;�'4°�a*'a a' .,l,`�.ft 3 a G 4 r,.�'T r�Sfi 3✓�Y�'k r"aty`3 v.;`�rt}r�:''��r r t�ri�s T�K�i{,r.�'�"��'a^`�H�h�5�x�t�.c?�n°�6"�ri ys h�.�'."x r,p_r X fc C R r„ v • S •.” " { �i E i `; § c v� �� , S S .t- �n„�c<s��-i��•u t F,,F<�3 a,f y r>-r.-.-. .h X v fi�8.'7 1 � lnv } } �n '. �iN�{{.��.` �::i.� ��.2.:�:1���.�:�vt "zti�� {^G��} 2 rw face .ern n� frWV 6 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 y NO — If YES,give details: 3. What action has been taken to prevent future incidents or claims? LMCITAPP.OML(I1197)(REV. 11(99) 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 open of the o en meeting law: 542- cv) etc 2. Have all new members attended the League Conference for Newly Elected Officials? �C 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, ...): c 5. Does legal council attend all official meetings? k 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: k YES NO 7. Please indicate the percentage of reimbursement of defense costs. 80% 100% X Y B :. • (Signature and Title of Authorized Representative) LMCITAPP.OML(11/97)(REV. 11-99) PAGE 3 OF 3 • City of Oak Park Heights 2003-2004 Insurance Estimate of Values Buildings $ 5,587,878 Park& Playground Equipment $ 415,727 Vehicles $ 223,766 Building Contents $ 214,309 Water Meters $ 190,933 EDP Equipment $ 130,404 Mobile Equip.1 $ 68,117 Utility Equipment $ 31,137 Police Department Equipment $ 30,397 Mobile Equip 2. $ 10,935 . Fire Safety Equipment $ 2.197 Total $ 6,905,800 o 0 0 o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o z r a r r r I- r N A. F+ 1-. 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