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' THIS IS AN APPUCATION FOR A CLAIMS MADE POLICY <br /> � � a . <br /> NATIONAL UNION <br /> FIRE INSURANCE COMPANY <br /> OF PITi"SBURGH, PA. <br /> c 7EcrioN <br /> A CAPITAL STOCK COMPANY <br /> (Herein called the Company) <br /> 70 PINE STREET, NEW YORK, N.Y. 10270 <br /> APPLICATION F�R <br /> PUBLIC OFFICIALS AND EMPLOYEES LIABILITY INSURANCE <br /> 1. Legal Name of Public Entity City of Decatur Illinois — <br /> Address 1N Ci�vic Centes QPlaza� �DP�'afit�T'� uscaca� �S�lz�p� <br /> 2. Public Entity was created in 1836 and derives its authority to operate as a <br /> �rea�� <br /> City under the laws of the State of Illinois <br /> (Gry.Counry,rown.Park D�stnct.etc.) <br /> 3. (a) Present Population 93,939 <br /> (b) If Public Entity is a Counry, name and population of largest City: <br /> n/a <br /> 4. (a) Names and Official Title of Governing Board Members <br /> NAME TIT�E ELE�TED APPO►NTED <br /> Gary K. Anderson Mayor X <br /> Erik Brechnitz Gouncilman X <br /> Steve John Councilman X <br /> Kent N. Mittelberg Councilman X <br /> William Mitchell Councilman X <br /> Shirley Moore Councilwoman X <br /> William Oliver Councilman X <br /> (�se a separate sheet of paper if additional space is required) <br /> (b) If Board Members are appointed, by whom ? n/a <br /> (c) If the appointing Board indic2ted in 4(b) presently carries Public Officials Liability or similar insurance, please defail the terms <br /> of such coverage: <br /> n/a <br /> 5. The following official or employee of the Public Entity is authorized and designated to receive any and all notices from the Company <br /> or its authorized representative(s) concerning this insurance: <br /> Gerard J. Bauer Risk Manager <br /> (NAME) (TITLE) <br /> 29297 (6/83) <br /> Paga 1 <br />