City Information

Name of City*

Address*

Name of Individual
Completing Form*

Title*

Phone*

Fax*

E-Mail*

Please provide estimated budgeted payroll by class code for the calendar year 2011. State classification description, number of full-time and part-time employees, volunteers, class code, and total payroll for that class code. Note that code 7370 (ambulance drivers) will no longer be used. All EMS-only personnel are now 7705 (both paid and volunteer staff). All personnel who do both EMS and fire fighting are firefighters (paid are 7710, volunteer are 7711).

Classification Description

# of FTE

# of PTE

# of Volunteers

Class Code

Payroll

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Has the City's exposure changed since reported last year? For example, have you added or deleted a new operational area, started using volunteer, inmate or community service labor, leased or chartered any aircraft and/or watercraft, or any other changes that might effect your exposure for workers' compensation.*

Yes

No

If Yes, please explain.

Section II: Physical Location of ALL City Employees
This is a requirement of our excess insurance carrier, and is part of the national terrorism coverage plan. Please answer the following questions, in full, pertaining to the location of employees (where employees report to work and/or are stationed). NOTE: If you have more than 4 physical locations, please send a separate list by e-mail or US mail to Deanna Myers Furman.

Site #1

Complete street address

Number of employees assigned to this address

Number of shifts at this location

Year structure at this location was built

Building construction type* (see code list to the right)

*Building Codes:
1. Wood Frame
2. All Metal
3. Steel Frame
4. Reinforced Concrete
5. Concrete Brick/Block
6. Earthquake Resistant

Has this building been retrofitted for earthquakes?

Yes

No

Site #2

Complete street address

Number of employees assigned to this address

Number of shifts at this location

Year structure at this location was built

Building construction type* (see code list to the right)

*Building Codes:
1. Wood Frame
2. All Metal
3. Steel Frame
4. Reinforced Concrete
5. Concrete Brick/Block
6. Earthquake Resistant

Has this building been retrofitted for earthquakes?

Yes

No

Site #3

Complete street address

Number of employees assigned to this address

Number of shifts at this location

Year structure at this location was built

Building construction type* (see code list to the right)

*Building Codes:
1. Wood Frame
2. All Metal
3. Steel Frame
4. Reinforced Concrete
5. Concrete Brick/Block
6. Earthquake Resistant

Has this building been retrofitted for earthquakes?

Yes

No

Site #4

Complete street address

Number of employees assigned to this address

Number of shifts at this location

Year structure at this location was built

Building construction type* (see code list to the right)

*Building Codes:
1. Wood Frame
2. All Metal
3. Steel Frame
4. Reinforced Concrete
5. Concrete Brick/Block
6. Earthquake Resistant

Has this building been retrofitted for earthquakes?

Yes

No

Section III: Electrical Exposure Supplement Application
Please complete the attached form if you operate an electric utility. Required whether or not you generate electrical power. The form used by KMIT is required by its excess coverage provider, Safety National (SNCC).

Effective Date: 01/01/2011

1. Name of City

Address

Type of Application

New Application

Renewal of Policy

2. Is any electrical power generated? If "yes", complete the following:

Yes

No

a. Amount generated as a percentage of total consumption ____%

b. Power source

Water Coal Oil

Gas Nuclear

c. Own or Maintain

Dams Coal Mines

Oil/Gas Field Pipelines

d. Power plants cooled by

Hydrogen Water

Oil

e. Does Applicant Subcontract Any of the Above Operations?

Yes

No

If Yes, please explain.

Does Applicant Agree to Provide Copies of Certificates to Excess Carrier on Demand?

Yes

No

2. Do employees construct, repair or maintain electrical power lines? (Includes excavation, the setting of poles, stringing of wires, installation of circuit breakers and transformers on poles and laying of underground cables.)

Yes

No

If Yes, please explain.

a. Does applicant subcontract any of the above operations?

Yes

No

If Yes, please explain.

b. Are certificates of workers' compensation coverage obtained from all subcontractors?

Yes

No

c. Does applicant agree to provide copies of certificates to excess carrier on demand?

Yes

No

4. Provide total number of commercial/industrial customers:

5. Provide total number of residential customers:

#6 Employee Duties

6a. Store employees, meter readers, drivers and administrative staff: Indicate Payroll and number of employees

6b. Operate, maintain or supervise equipment and facilities associated with the generation/distribution of power: Indicate payroll and number of employees:

6c. Power line construction: Indicate payroll and number of employees:

6d. Other (list duties): Indicate payroll and number of employees:

6e. Additional Comments:

This is NOT a binder of coverage. The application must be signed or electronically signed by the city's representative. The city represents that all statements made in this application are complete and true and that all material facts have been disclosed.

Name of City's Representative Signature

Date Completed:

Safety National Casualty Corporation
1832 Schueltz Road, St. Louis, MO 63146; Phone (314) 995-5300 Fax (314) 995-2843