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LEAGUE OF MINNESOTA CITIES INSURANCE TRUST <br />ACCIDENT PLAN FOR CITY VOLUNTEERS <br />Application for Coverage <br />The City of hereby requests coverage under the League of Minnesota <br />Cities Insurance Trust's Accident Plan for City Volunteers effective <br />pay the premium established by LMCIT for that coverage. <br />Optional coverages to be included: <br />$1,000 medical coverage Yes No <br />Construction or demolition project Yes No <br />Please describe each construction or demolition project to be covered, including the nature and <br />scope of the project, the dates, and the approximate number of volunteers who will be involved. <br />and agrees to <br />Signature: <br />Date: <br />Position: <br />Return this form to LMCIT, 145 University Ave. W., St. Paul, MN 55103 -2044, Attention: Barb <br />Meyer. <br />Thus material Is provided as general Information and Is not .a substitute for legal advice. <br />Consult your attorney for advice concerning specific situations. <br />