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O0 <br /> LEAGUE OF CONNECTING & INNOVATING <br /> MINNESOTA SINCE 1913 <br /> CITIES <br /> LIABILITY COVERAGE—WAIVER FORM <br /> Members who obtain liability coverage through the League of Minnesota Cities Insurance Trust(LMCIT) <br /> must complete and return this form to LMCIT before the member's effective date of coverage.Return <br /> completed form to your underwriter or email to pstechnlmc.org. <br /> The decision to waive or not waive the statutory tort limits must be made annually by the <br /> member's governing body, in consultation with its attorney if necessary. <br /> Members who obtain liability coverage from LMCIT must decide whether to waive the statutory tort liability limits <br /> to the extent of the coverage purchased. The decision has the following effects: <br /> • If the member does not waive the statutory tort limits, an individual claimant could recover no more than <br /> $500,000 on any claim to which the statutory tort limits apply. The total all claimants could recover for a single <br /> occurrence to which the statutory tort limits apply would be limited to $1,500,000. These statutory tort limits <br /> would apply regardless of whether the member purchases the optional LMCIT excess liability coverage. <br /> • If the member waives the statutory tort limits and does not purchase excess liability coverage, a single claimant <br /> could recover up to $2,000,000 for a single occurrence (under the waive option,the tort cap liability limits are <br /> only waived to the extent of the member's liability coverage limits, and the LMCIT per occurrence limit is <br /> $2,000,000). The total all claimants could recover for a single occurrence to which the statutory tort limits apply <br /> would also be limited to$2,000,000, regardless of the number of claimants. <br /> • If the member waives the statutory tort limits and purchases excess liability coverage,a single claimant could <br /> potentially recover an amount up to the limit of the coverage purchased. The total all claimants could recover for <br /> a single occurrence to which the statutory tort limits apply would also be limited to the amount of coverage <br /> purchased, regardless of the number of claimants. <br /> Claims to which the statutory municipal tort limits do not apply are not affected by this decision. <br /> LMCIT Member Name: Sherburne Wright Counties Cable Communications Commission <br /> Check one: <br /> ❑✓ The member DOES NOT WAIVE the monetary limits on municipal tort liability established by Minn. Stat. <br /> 466.04. <br /> ❑ The member WAIVES the monetary limits on municipal tort liability established by Minn. Stat. & 466.04, to <br /> the extent of the limits of the liability coverage obtained from LMCIT. <br /> Date of member's governing body meeting: <br /> Signature: Position: Treasurer <br /> 145 UNIVERSITY AVE. WEST PHONE:(651)281-1200 FAX:(651)281-1299 <br /> ST. PAUL, MN 55103-2044 TOLL FREE:(800)925-1122 WEB:WWWLMC.ORG <br />