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U <br />PUBLIC OFFICIALS LIABILITY INSURANCE <br />THIS IS A PROPOSALVOR•ABLl1tM WADE POLICY <br />1. Legal Name of Public Entity Ci i;nf Mnunda Vi pw <br />Address 2401 Highway 10 Mounds View MN 55112 <br />(Number) (Street) 4CIty) (State) (Zip) <br />Telephone Number (Area Code) 1 612 ) 7H6 1099 <br />2. Public Entity was created In 1979 and derives Its authority to operateas a City <br />!year) (City.Gounty, Town, Park District, etc.) <br />3. Present Population 12, 593 <br />4. Names end Official Tilles of Governing Board Members <br />NAME TITLE -ELECTED APPOINTED <br />Duane McCarty Mayor xv <br />Jerry Linkp Cnuncil Member X <br />Phyllis Blanchard Council Member X <br />Dill 11nt Cnrmril Mpmhpr Y <br />Sue Hankner Council Member % <br />(Use Page 4 N Additional space is req*W) -- <br />Listing of officials does not Insure coverage, such coverage being limited to the definition of Insured in the policy. <br />5. The following official or employee of the Public Entity Is authorized and designated to receive any and all notices from the <br />Company or its authorized represenlalive(s) concerning this insurancs. <br />Donald Rraypr Finance Director <br />(NAME) (TITLE) <br />(ADDRESS, N different from above) <br />6. List any subsidiary boards, commisssions,euthorltlesorotherunits operating underthe jurisdiction ofthePublic Entityand <br />within an apportionment of Its total operating budget. Please indicate 00 unit presently carry their own Public rDfflcials <br />Liabililv Insurance. If no such units are in operation, so AM: Mounds View arks. Recreation & Forestry <br />Commisgio Planning & .nni g Co miecinn - non hay a prate insurance contract <br />It is warranted that the figures shown in items a and 10 below Mdude the budget of arch board, commission, authority or <br />other unit herewith listed. <br />7. Fiscal Year ends on 12/31 <br />ba. Budget Current Fiscal Year 1984 Levy Estimated Surplus or 0WIcIl) <br />t 859,623 _ _; -0- <br />b. hsconta Prior 3 Fiscal Years <br />fr4wWfures Prior 7 Flscal Tams <br />Og.83._i 773,550 6 - <br />19 89 $ 744.191 $ <br />lg 81 If 723,550 _ N <br />W <br />L IU, <br />r - 1 '.+ <br />Zm <br />