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5. <br />6. <br />/. <br />8. <br />9. <br />Principal purpose of joint use dock is (check applicable items): <br />X 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 />X 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 anu ownership information; ^ ^ <br />Street address ^.^5" / <br />orthiWest), <br />YSoutl^ast) <br />Names of abutting lakeshore property owners: ^ <br />(Name + Address) <br />Mg.vTW LXrvjyVL <br />(Name + Address) <br />Names of other affected property owners: J <br />+ Address) (attach sheet if necessary) Pr, <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____----------------------------------------------------------------- <br />Name of insurance carrier ^ / __________________/* A-^ /- <br />Name of insurance agency X'-T. <br />Policy No.__________________Effective date of coverage ------------— <br />Amount of coverage: Public liabUity, per person, per occurrence <br />Public liability, per occurrence $----------- <br />Page 2 of 5