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6. <br />7. <br />8. <br />Dock is located on (check applicable item): <br />one member's private property. <br />easement or outlot owned in common. <br />property leased by the group/association, <br />property owned by the group/association. <br />List Dock location and ownership information: <br />Street address 0^15 ^ ^ ^ <br />Legal property description _____________ <br />PIP# 2*2. <br />Listed property owner(s) <br />Names/addresses of abutting lakeshore property owners: <br />CNorth/West)________________________________ <br />f South/East) <br />Names/addresses of other affected property owners (attach sheet if necessary): <br />9. Insurance Coverage - The jointly used dock is insured by one of the following: <br />A property owner's homeowner's policy. __separate group/association owned policy. <br />List the following information: <br />Name of insured ^W\ <br />Name of insur<ince carrier <br />Name of insurance agency <br />Effective dPolicy No. CfP^fr^T <br />Amount of coverage: Public liability, per person, per occurrence $__h <br />Public liability, per occurrence $ f,000,0£'^ <br />ate of coverage 2. / / QQ <br />L ner occurrence's COO <br />10. Security and policing of the jointly used dock an ^ piu. provided by (check applicable <br />items): ^ <br />X. security lighting ____ property owner's presencetencmu <br />W <br />contract security service other (specify) <br />DOCK INFORMATION <br />11. List Dock Use Area Specifications: ^ <br />Width of shoreline: ft. Length of main dock from shore: _»!____ft. <br />20 ft. and 40 'Dock setbacks from side property lines at shore:ft. <br />Page 2 of 4 <br />i