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5. <br />6. <br />7. <br />8. <br />9. <br />X incorporated club or recreation group. <br />Principal purpose of joint use dock is (check applicable items): <br />____provide boat mooring and laxe access for residential property. <br />____provide swimming access, beach, or offshore dock. <br />provide a club or association gathering place for activities. <br />Dock is located on (check applicable item): <br />____ one member’s priwi? property. <br />____ easement or outlot owned in common. <br />___ property leased by the group/association. <br />__ property ow ned by the group/association. <br />List Dock location and ownership information: <br />Street address and 19, located on Big Island, Orono, Minnesota <br />Legal property description see attached Exhibit A <br />PID# _______________________________ <br />Listed property ow’ner(s) Bia Island, Inc <br />i^.O. Box 1R8, Excelsior, W 55331 <br />Names of abutting lakeshore property ow ners: <br />(NorthAVest) unknown — believe to be Erickson <br />(Name + Address) <br />(South/East) n/a <br />(Name Address) <br />Names of other affected property ow ners: <br />n/a <br />(Name + Address) (attach sheet if necessary) <br />Insurance Coverage - The jointly used dock is insured by one of the following: <br />____ property ow ner's homeow ner's policy. <br />separate group/ ssociation owned policy. <br />List the following information: <br />Name of insured Island, Inc. <br />Name of insurance carrier St, Paul Reinsurance <br />Name of insurance agency Erickson-Larsen, Inc.__________________ <br />Policy No. S-2363-’^IN________ Effective date of coverage 06/29/96 ~ 06/29/97 <br />Page 2 of 5