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League of Minnesota Cities Insurance Trust <br /> Group Self- Insured Accident Plan for Volunteers <br /> 145 University Avenue West <br /> St. Paul, MN 55103 -2044 <br /> ACCIDENT PLAN FOR CITY VOLUNTEERS APPLICATION <br /> City of Centerville <br /> Please check the coverages the city wants quoted. <br /> Accident Plan for City Volunteers (includes coverage for members of advisory boards and <br /> committees) <br /> D Basic coverage (no medical) <br /> ® Basic coverage (with medical) <br /> Accident Plan for Members of Advisory Boards and Committees Only (no coverage for other city <br /> volunteers). Please provide the number of advisory boards and committees and the number of <br /> members. <br /> Park and Recreation Committee - 7 Members <br /> O Basic coverage (no medical) <br /> ® Basic coverage (with medical) <br /> If you have any questions, please contact Barb Meyer at bmever@imc.org or 651- 215 -4173. <br /> Mike Jeziorski <br /> Finance Director 1/6/12 <br /> Signature Title Date <br /> 4 <br /> 24 <br />