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• Cl Wro^glut or alledgtd wrongful approval of budding pWr, deafgnt or tptcihuttme Yee_ No <br />D► Wrongful or alledged wrongful approval of building construction Yw_No_ Y_ <br />E) Wrongful or alledged wrongful trtalmint regarding employee hiring, remunorstim <br />advancement or termination of employment Yp_No <br />F) Disputes Involving Integration, oegregation, discrimbrift , or violation of tint nghb Ya_ No_i_ <br />0) Any grand jury Invesllgetion, reWl proceedings or IndICMV l* of any public official* Yee —No _ I <br />IS. No fact, circumstance orsitutalionindicaling7heprobaNityofaclaimoreetlonagsimtwhlchIndemnification isorwould be <br />afforded by the proposed insurance is now known to any official or employee of this Unity, andb Is agrtacl by all concerned <br />that If there be knowledge of any such fact, circumstance orsituatlon, any cldm or action subsequently emanating therefrom <br />Shall be excluded from coverage under the proposed irtwrfull �. <br />19. Limit of liability desired: (The slandlyd limit of liability IS $1,000,000. It you desire different limits please so Indicate.) <br />S 1,000.000 eachclaimand$ 1,000,000 aggregate• <br />20. Sell Insured retentions (S,I,R) are based on the following population basis and will form a part of your policy unless an <br />alternate Is selected. <br />POPULATION S.I.R. <br />250.000 and over $10.000 <br />100.000 to 249.999 S 7.500 <br />50,000 to 99,999 S 5,000 <br />25.000 to 40.999 $ 2.500 <br />24,999 and under $ 1,000 <br />21. Optional sell -insured retentions may be requested for alternate quotation. Please indicate S.I.R. desired $ # <br />Desired effective date, if purchased MAY 1 198 <br />?2. The under- gned who are authorized to sign this Proposal declare to the best of their knowledge and belie', the statements <br />set forth herein are true SIGNING THIS PROPOSAL DOES NOT SIND THE APPLICANT OR THE COMPANY TO <br />COMPL ET E THIS I NSURANCE, but it is agreed that Ines fonnshafl be the basis of the contract thou;d a policy be issued and <br />this form Shall attach to and become a part of the policy. <br />TWO SIGNATURES ARE REQUIRED <br />A, <br />Signed Date . <br />(name) (title) <br />Signed <br />a $250/$100/$2,500 <br />(namey <br />Date <br />Submitted by: <br />hMS <br />