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UNITED FIRE & CASUALTY COMPANY <br /> CEDAR RAPIDS, IOWA <br /> (HERUMAlTER GALLED SURETTI <br /> APPLICATION-QUESTIONNAIRE FOR <br /> A PUBLIC EMPLOYEES BLANKET BOND OR <br /> A PUBLIC SCHOOL SYSTEM EMPLOYEES BLANKET BOND <br /> App;italiy. .s herebe ..+de by CITY OF ST. ANTHONY <br /> 19­1 C01.9-0 <br /> (here•.cooed Cbl:gee) for the se and benelil of Citv of St. Anthony Various Officials <br /> (E.KI^r.•.../I.....al <br /> 3301 Silver Lake-Road,-.Minneapolis, Minnesota 55418 .,,fe,,C1lledln,Iredl <br /> of <br /> Ill­,) IC•t.r IStu.l <br /> lo, co.e•a.;. uncle• the bonJ designated be:ow -:th respect to such of the following Inwrir.g Agreer.•enes opoctite -h:ch a. a..a1.r is <br /> swcj. to beta-•e ellect..e ar to be cann.ued as of <br /> ►.blie E^s.le,..s 111..6.1 l..d C', F.bl;e Sel..wl S,I1•... E.-e:.!••■ Bl..:.r O..J ❑ <br /> I.I.....y Afire• ..r I H*.csry 814n6er 90nd Co..•age . . . . . S <br /> In.-..y A�.ee•..r I MoneNy Blan:el Pa,.l.o. Bond Co-II-ge S <br /> In w.'y Aye. ..t 7 iaahlu! Perfar...anee 81a 1kat Bond Ca-erage . . . . - $ <br /> f.. ...� •�... ..r t Fa.rhlul Perlo,-ance Blanket Paur.on 9ond Co.erage . . S 100,000 <br /> P•e-^i.- p..able: p...a:d ❑ I V,.. a 7 ,,1. ❑ ] "J.. O a .rs. .trdl....r. ❑ ] yn.. (3,t ,It. <br /> 1. (al Is rh. Inswed a wr al the go-e-­r of the Slate ❑. county ❑. city ❑. law.❑.•ilt.go ❑ or arks poi:t.cal wbdl-";.. ❑. <br /> and If la,r.stare-h.ch. <br /> (bl if ih.t is for a Publ:e E�vloy.es 9lsnier Bend.is a School Sysle•. part of the (.cared? <br /> (e) L.st alt wbord:n+te depart..e.ts. di.:s:ont. oll.ees or institutions which the Insured is authorised by law to manage. C.-ern at <br /> con.ral. <br /> 2. G• a total I.-bc,of pe,wm c-ola..d b,, Insured.the Ins 75 <br /> ]_ <br /> .11—,)-.e Inwred arran;e t_o ha.e I.- E.-pto.ees con alete personal acol:canons (tuaoGed b.. S..rerrl? YPR <br /> A. Is Iher. l:4viy re be a "Ila.t.a( :nvease :n the • -be&o E rroioyees during the prrr.:u.. per.ed by reason of % awn.l acli-ly ar - <br /> wher c••ev.r•uancas petu:ar <br /> to 1.w_red's lured nl 11VV <br /> S. A!I;,I__ I+I No- frcCVe•r7. -,de? Annually/Month On (bl Are all Ixal;-%;•cluded? Yes <br /> • (cl•9, -1,0-? C?A: .Sratl.Audaor: -Liquor <br /> others-:e.ala.n I.dl.l OutsidpCPA Stuart J. Bonniwell CPA <br /> !.:r a,.j.t...dc? June. 1988 1.1 Period :a.-r.d Calendar 1987 <br /> (fl We•e am d:se•ea•s•c.es or loose praet.ces ca^^e•ted uoan? 11 w. sub-; a copy of aud:r ar aud:roi t ta^^cites. , <br /> 6. Losses of a nature-h•e.-wld ha•e bee•+tv.<.ed b.•he bo•d aoo::ed let (p+st S .eanJ- et4 it .cite ❑ <br /> --.•Dare A.••ounr I Era:e.te'i 7aur:on Ca••eeti.e M......I Taken(Orh.e 7}...O.se`•r;el ' <br /> 7. P.es_cnr ca-e•age •n !a•:e-C�eci .1 rone ❑ <br /> Fors�f Bond i E!tecr.•e Oate I A-. t N.rr.e of Ca^p+n. <br /> Use seaarare sheet it nftnw". <br /> B C.-elete th. ClatdG ur:a. el F-ele,e.s .. •— <br /> 9. If•adCa.onal .nde^^.. land.• +n. I,wu g AC.e.^en1 is des.•.d en any oos.r.e.•ca-olete the follow.'": <br /> Inwri hlurnber Aneunr of <br /> o. <br /> Loea.. ( A rren..nr I of Er^oloyees I Addido. ^W <br /> .l Inde iry <br /> S Total n EKE Pa,.do.. e.Each-E-91o•te <br /> r I I I .. <br /> 1 I I <br /> Oared ar tlss day of 19 <br /> lQ•r[Ar p.w.gl <br /> uim-2o62b <br /> By (r.na <br />