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6. <br />7. <br />8. <br />9. <br />10. <br />Dock is located on (check applicable item): <br />___one member's private property.property leased oy the group/association. <br />easement or outlot owned in common. property owned by the group/association. <br />List Dock location and ownership information: <br />Street address H <br />Legal property description <br />Names/addresses of other affected property owners (attach sheet if necessary): <br />>l/c/vO______________________________________ <br />Insurance Coverage -The jointly used dock is insured by one of the following: <br />property owner ’s homeowner ’s policy. _^separate group/association owned policy. <br />List the following information: <br />• Name of insured C0{jA~frtd djulO _________ <br />Name of insurance cairier Li)€<kr / <br />Name of insurance agenev r\slj) U) <br />F’olicyNo. (i(P iN () 1 ^ 0 1/> Effective date of coverage 7- 3^-6^ 7-3 ^ ^Cffj <br />Amount of coverage: Public liability, per person, per occurrence $ <br />Public liability, per occurrence $ <br />Security and policing of the jointly used dock and property is provided by (check applicable <br />items): <br />fencing security lighting property owner ’s presence <br />____contract security serv ice _____ other (specify)_______________ <br />DOCK INFORMATION <br />11. List Dock Use Area Specifications: <br />Width of shoreline: ft. Length of main dock from shore: <br />Dock setbacks from side propertv lines at shore: '3Cy ft. and So <br />ft. <br />ft. <br />Page 2 of 4