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• • 12-6-84 <br />PnooUCER CAHRIER UNOERWIIITER <br />National <br />_Guarantee <br />Lyon Agency, Inc. I'OLICIES 09 PROGRAM REOUESTEO <br />1421 E. Wayzata Blvd. Prize Indemnification Policy - Limit of Liability $10,000 <br />Wayzata, MN 55391 PLEASE INDICATE THE SECTIONSATTACHED <br />❑ PROPERTY ❑ GENERAL LIABILITY ❑ UMBRELLA <br />❑ GLASS &SIGN ❑ BUSINESS AUTO ❑ <br />❑ ACCTS. REC.NAL. PAPERS ❑ GARAGE ❑ <br />CODE SUBCOOE ❑ CRIME ❑ FIDELITY ❑ TRUCKERS ❑ <br />❑ TRANSPORTATION ❑ WORKERS COMP. ❑ <br />POLICY• <br />❑QUOTE ❑ISSUE POLICY ENTER THIS INFORMATION WHEN C014MON DATES AND TERMS APPLY TO SEVERAL LINES <br />M 9OUND(G,WO.I..W,1A„rtNCc,,) PROPOSED EFF. DATE PROPOSEDEKP. DATE BILLINGPLAN PAYMENTPLAN AUOIE <br />12-6-84 ... 1-29-85 1-29-85. - IAGENCYRILL <br />DIRE TRILL <br />• <br />NAME <br />Orono Hockey Boosters A <br />.. --Terry Feldmann's Imports, Inc. .. <br />MAILING ADDRESS IIm1YM Zip CpaPl <br />_ - M a 9 <br />❑ INDIVIDUAL ❑ CORPORATION ID OTHER IDESCRIBEI <br />IFFIA. BuS..E51 <br />❑ PARTNERSHIP ❑ ,gINT VENTURE "— <br />INSPECTIONICnvscnPMml IACCOLWTING RECORDS ICpmMNnan•I <br />Dick Raiche, Orono Hockey Boosters, 476-1601 <br />UP <br />• <br />STRE:- CITY, COUNTY, STATE. ZIPCODE INTEREST <br />WEBUILT PART OCCUP'ID <br />I <br />• •IBMF <br />The insured is selling raffle tickets, for a chance to win a car valued at $10,000. Ten <br />tickets will be drawn. The holder of the ticket will then be asked to shoot a hockey puck <br />at a hole cut in a board that will be placed in front of the net. If the puck goes through <br />the hole, the shooter wins the car. The named insured agrees to the following stipulations: <br />(1.) The hole in the board will be VxV. (2.) The ticketholder will shoot from center <br />ice. (3.) The ticketholder will get only one shot. (4.) A referee will be positioned <br />at center ice and at the goal line. (5.) A representative of the named insured will <br />witness the event. <br />• <br />EKPLAINALL"YES "RESPONSES <br />Yw MOP <br />EKPLAINALL-YES"RESPONSES IV. NIP <br />1 <br />1, tM.pynpM. w4,0u1Y o1.MIMr mn1Y pr pow <br />. <br />AnY E.,NnnpM upowr0 n ❑ <br />m..PPIK.nI Mre .nY we,reN.rw, N/A <br />❑ ❑ B <br />AnrPiMrrrrW.•MY w.m lm,Pwr'wM p•MnP wl,mnlrol C <br />Anr rolRr w cpwl.w pwnme, nmPlNe p, N/p <br />o-r•n.w•p por mOlM prmrlq.n> ❑ ❑ <br />] <br />N • mrw•I mar woewn M epwnron, <br />❑ ❑ B <br />❑ ❑ <br />AnY ..pown ,o ll.mrMOb. Upbuvw,FMmruN, <br />REMARKS <br />The ten names will be drawn on 1-27-85, at 1:00 P.M. The event will take place on 1-29-85, <br />between period of the Mound/Orono hockey game, at `&WZd ' F.,,d Q9(ATW <br />Annual premium of $2,000 has been received. <br />"'1 IL AN I'S <br />1 / <br />/ <br />PPUUVTI {15 <br />4 I <br />.4AIHRf <br />�..�• .'- <br />Sr4 NAlUN1 <br />