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5. <br />6. <br />8. <br />9. <br />Principal purpose of joint use dock is (check applicable items). <br />,/ provide boat mooring and lake 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 private property. <br />v/" easement or outlot owned in common. <br />property leased by the group/association, <br />property owned by the group/association <br />7. List Dock location and ownership information; <br />1/Street address ‘ (j J <br />Ugal propeny rf^.^riminl, niltir)^ A (Ma <br />Listed property owner(s) \j \(X I j <br />Names of abutting l^eshore property owners; <br />rNorth/We^> <br />W/>l <br />(Name Address) <br />(Name + Address) <br />Names of other affected property owners; <br />(Name + Address) (attach sheet if necessary) <br />Insurance Coverage - The jointly used dock is insured by one of the following; <br />property owner ’s homeowner ’s policy. <br />^ separate group/association owned policy <br />List the following information; <br />Name of insured flfK 9MM <br />Name of insurance carrier i iJt/^ (l <br />Name of insurance agency <br />mm nimwAiP- — <br />Name oi insurance agency ^ ^----j------ <br />Policy No. Effective date of coverage (?i f^— <br />Amount of coverage; Publicliability, per person, per occurrence <br />Public liability, per occurrence $ ^W\WD- <br />Page 2 of 5