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6. <br />7. <br />0’ <br />9. <br />10. <br />Dock is located on (check applicable item): <br />___one member's private property. <br />\/easement or outlet 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 /l/ S3 Y <br />Legal property description (Sj <br />PIP# <br />Listed property owner(s) “TivA ^ro(I *.'70^ <br />7 <br />Names/addresses of abutting lakeshore property owners: <br />fNorth/WesO 'TO/y\__LU^(^(\ flJ \jr._____________. ^________________ <br />fj/ ftf^n jOf.^ <br />ners (attach sheet if necessary): —SqP_. <br />rSouth/EasO <br />Names/addresses of other affected property owners <br />In^rance Coverage ^th <br />anectea property owners (.anacn sn^et ii necessary;: —qxJ' <br />e jointly used dock is7nsure'<fby one ot the^ollown^ - <br />property owner ’s homeowner ’s policy. L/^parate group/association owned policy. <br />List the following information: <br />Name of insured \J i C'________________ <br />Name of insurance carrier 4^/'; t i1 n f~ry71 / <br />Policy No <br />Amount of coverage: Public liability, per person, per occurrence $ SoO^ <br />Public liability, per occurrence % ^ /i7j V <br />Security and policing of the jointly used dock and property is provided by (check applicable <br />items): <br />____ fencing ____ security lighting V property owner ’s presence <br />r\speci <br />'y/ieQ'ii'nc <br />nsuranceearner t/,/i /^iLJTUa/ <br />instance agency <br />'-'^SI • hey?^ Effe(/tive date of covera^ ^ -77^ <br />contract security service other ^specify) <br />DOCK INFORMATION <br />11. List Dock Use Area Specificati^j;^ U C7\ <br />Width of shoreline: j l) 0 ' Length of main dock from shore: <br />Dock setbacks from side property lines at shore: ^00 ____ ft. and % 0^ ft. <br />Page 2 of 4