Laserfiche WebLink
NAMED INSURED INFORMATION <br /> Cite of Decatur DBA Decatur Public Transit <br /> I Name(include DBA): System Year Established: <br /> CompanyType: [I Individual Partnership El Corporation Z Other: <br /> 3, Contact, Jerome M Parker Title: General Manager <br /> 4. Mailing Address: —Same <br /> Street!Citv Count}' <br /> State Zip <br /> Business Address: 555 East Wood Street Decatur IL 62526 <br /> Strecu'CitN: Count} state Zip <br /> Telephone: (2 17) 424-2814 Fax: (217) 424-2818 <br /> FEIN#: 47-1122993 <br /> 6. E-Mail Address: jparker Cq,,decaturil.gov Website Address: <br /> 7. Narne of all entities to be insured,year established and detailed description of each operation: <br /> Entity Year Description <br /> Established 1 of Operations <br /> A. <br /> B. <br /> C. <br /> D. <br /> S. Full address of each entity to be insured and relationship(i.e._ wholly-owned subsidiary, parent, etc.)to Named Insured: <br /> Entity <br /> Address <br /> Relationship <br /> A. <br /> B. <br /> C. <br /> D. <br /> 9. Provide the following information for all officers,directors. partners and stockholders of the Named Insured: <br /> Years <br /> Position I Full Time/ 1 <br /> Name No,of f Transit 1 pet. <br /> Function Part-Time Years <br /> Experience 1 Ownership <br /> A <br /> V-Lq <br /> j e's <br /> 10. Provide the name(s)of any public transportation entity(ies)not covered under this application in which the Named Insured <br /> or any of its officers, directors, partners or stockholders have a direct or indirect Ownership interest: (if None.state None) <br /> H. Any o%N nership in non-transportation related business? [I Yes Fj No If Yes, please specify. <br /> ancor Rus/Long Application(09)'13) Page 2 ofl 0 <br />