2002-04-01 Insurance
"'SeJ
-
e
FAX TRANSMITTAL
1200 25th Avenue South, P.O. Box 1717, St. Cloud, MN 56302-1717
320.229.4300
800.572.0617
320.229.4301 FAX
o FIELD OFFICE:
SEH FILE NO:
A-ALBEV 0110.00 14
DATE:
April 1, 2002
Debbie Gilyard
FROM:
TOTAL PAGES:
2
(including cover sheet)
D URGENT
A TTENTION: Scott Dahlke
. CO/ORGANIZATION: Quality Site Design
FAX NO: 1.763.550.3913
TELEPHONE: 1.763.550.9056
SUBJECT: Heuring Meadows, Albertville, MN
REMARKS:
Revise and resubmit Certificate of Insurance as follows:
· Revise Owner/Engineer Protective Liability naming both the City of Albertville and SEH as
additional insured.
· Revise cancellation clause as follows:
"Should any of the above described policies be materially changed, suspended, or canceled before
the expiration date thereof, or fail to be renewed upon their expiration, the issuing company will mail
30 days prior written notice to the named certificate holder."
C: Scott Hedlund, SEH
Linda Goeb, City of Albertville (w/enc1osure)
We are
IZI Sending original by mail
IZI Sending by FAX only
o Sending as requested
For your
IZIlnformation/Records
o Action
o Review and comment
o Distribution
o Approval
IZI Revision and resubmittal
If transmission was not received properly, please contact the sender at the phone number above
WE REQUEST A RESPONSE FROM YOU BY: 04/05/02
djg
W:\albevlO II O\corrlF-quality-04O I 02.doc
12/00
Short Elliott Hendrickson Inc.
.
Offices located throughout the Upper Midwest
We help yau plan, design, and achieve.
.
Equal Opportunity Employer
we
ACORDN
CERTIFICPJ
OFLIABllITY'INSl:JNC,a:: OPID D DATE (MM/DDNY)
. ... ~PUTI-1 03/15/02
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PRODUCER
Apollo Insurance Agency
POBox 1206
St Cloud MN 56302-1206
Phone:320-253-1122 Fax: 320-253-9969
INSURERS AFFORDING COVERAGE
INSURED
R P Utilities Inc
POBox 829
Annandale MN 55302
INSURER A
INSURER B:
INSURER C.
INSURER D
INSURER E:
Transportation Insurance Co
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
'~-FR' TYPE OF INSURANCE POLICY NUMBER DATEiMM/DDNYI DATE IMMlDDIYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $1,000,000
-
A X COMMERCIAL GENERAL LIABILITY C1073046728 03/31/02 03/31/03 FIRE DAMAGE (Anyone fire) $ 100,000
I CLAIMS MADE ~ OCCUR MED EXP (Anyone person) $ 5,000
X Blk t Addl Insured PERSONAl & ADV INJURY $1,000,000
-
- GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $1,000,000
I n PRO- nLOC
POLICY JECT
AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT
- $1,000,000
B X ANY AUTO C1073046731 03/31/02 03/31/03 (Ea accident)
-
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
-
~ HIRED AUTOS BODILY INJURY
$
X NON-OWNED AUTOS (Per accident)
-
- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
=1 ANY AUTO OTHER THAN EAACC $
AUTO ONLY: AGG $
EXCESS LlABIUTY EACH OCCURRENCE $1,000,000
A ~ OCCUR D CLAIMS MADE C1073046759 03/31/02 03/31/03 AGGREGATE $1,000,000
$
~ DEDUCTIBLE $
X RETENTION $10,000 $
WORKERS COMPENSATION AND I TORY LIMITS I IUElt
C EMPLOYERS' LIABILITY WC173046745 03/31/02 03/31/03 $500000
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE $500000
E:L. DISEASE - POLICY LIMIT $1000000
OTHER
.
- r- --,- ........ _w
DESCRIPTION OF OPERATIONSlLOCA TIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS 1 ~' ,: Ii ~ I \
Project: Heuring Meadows Street and Utility Improvements, Albert '1 lc.JJ.- II \V C;".
j "' 18~OO~ ~
R,P. Utilities, Inc, Job #01-02. mi~~~
-
CERTIFICATE HOLDER I N I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION 0Mun I 'c ~7~~~ ).i n~\r;:;~ ~,i;.: ,--
SHOULD ANY OF THE ABOVE DESGRlBE&. _~_~_ - ,
SEHENGI 110
.."",,"""". "" OSSUONG ~ ...,...""" ro.... 2L..", """'"
NOTICE TO THE CERTIFICATE HOLD N D TO THE LEFT, BUT FAILURE TO DO so SHALL
SEH IMPOSE NO OBLIGATION OR LIAB ITY ANY KIND UPON rp7R. ITS AGENTS OR
1200 25th Ave S
p, 0, Box 1717 REPRESENTATIVES. I .I,
St, Cloud MN 56302 AUTHORIZED REPRESEtlTA]J////"_ \. ~
1 Steve, Eskra r '"'t -
ACORD 25-8 (7/97)
) ACORD CORPORATION 1988
....se~
-
1200 25th Avenue South, P.O. Box 1717, St. Cloud, MN 56302-1717
TO: Linda Goeb
City of Albertville
320.229.4300
RE: 2001 Heuring Meadows, Albertville, MN
We are
181 Enclosing
1 Certificate of Insurance dated 06/26/02
For your
181 Information/Records
o Action
REMARKS:
BY: Debbie Gilyard
c: Scott Hedlund, SEH
djg
w:\albev\OIIO\corr\t-city msurance-020602.doc
Short Elliott Hendrickson Inc.
.
o Sending Under Separate Cover
o Review
o Distribution
Offices located throughout the Upper Midwest
We help you plan, design, and achieve.
e
TRANSMITTAL
800.572.0617
320.229.4301 FAX
February 6, 2002
Date
A-ALBEV 0110 14
File Number and Location
Client Number
181 As Requested
o Approval
o Revision and resubmittal
l2Ioo
.
Equal Opportunity Employer
)
. MN-COMMERCI. LINES e
COBB STRECKER DUNPHY & ZIMMERM, MINNEAPOLIS, MN 55402-
612-349-2449 * FAX 6123492491
SagiFAX Cover Sheet
FAX TO:
DEBBIE GILYARD
SEH
9,13202294301
DEB
FAX FROM:
DORIS L. LAVOI
CSD&Z
612-349-2449 / FAX 6123492491
FAX DATE: February 6, 2002 FAX TIME: 10:59am NUMBER OF PAGES (INCLUDING COVER): 4
COMMENTS:
Please see attached amended Certificate of Insurance.
02/06/02 WED 11:57 [TX/RX NO 9189]
.
SAGIFAX
206102 10:59AM
CSD&Z\....J..J..\::::!11L.1t; "I
nU.1.J.1.J\....Vl\1.1
PRODUCER
PAGE 1
ACORDN CERTIFICAW: OF LIABILITY INSUR.CE o2iIO~/b2
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
MN-COMMERCIAL LINES
COBB STRECKER DUNPHY & ZIMMERMANN
150 S FIFTH ST STE 2000
MINNEAPOLIS, MN 55402
INSURERS AFFORDING COVERAGE
INSURERA: CINCINNATI INSURANCE COMPANY
INSURED
MATT BULLOCK CONTRACTING CO INC
14233 42ND ST NE
ST MICHAEL, MN 55376
INSURER B:
INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXClUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID ClAIMS.
INSR TYPE OF INSURANCE POLICY NUMBER "<<g~'iJI~FJ/~Cri~ P~~~~ ,~~'rDAri~ LI MITS
LTR
A GENERAL LIABILITY CPP0677450 02/01/02 02/01/03 EACH OCCURRENCE $1, 000,000
~~I ''"""' G" '""' ,.,"~ FIRE DAMAGE(Anyone fire) $100,000
I CLAIMS MADEOO OCCUR INCLUDES: MED EXP(Anyoneperson) $5 , 0 0 0
X CU OPERATIONS OF SUBS- PERSONAL & ADV INJURY $1,000, 000
X lBROAD FORM PD CONTINGENT GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: CONTRACTUAL LIAB PRODUCTS -COMP/OP AGG $2,000,000
n ,nPRO- n
POLICY JECT LOC
A AUTOMOBILE LIABILITY CPP0677450 02/01/02 02/01/03 COMBINED SINGLE LIMIT
~ ANY AUTO (Ea accident) $1,000,000
I ALL OWNED AUTOS BODILY INJURY
I---i $
~ SCHEDULED AUTOS (Per person)
, I HIRED AUTOS BODIL Y INJURY
~ $
I i NON-OWNED AUTOS (Per accident)
I PROPERTY DAMAGE
I (Per accident) $
GARAGE LIABILITY AUTO.oNLY - EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
A EXCESS LIABILITY CCC4410654 02/01/02 02/01/03 EACH OCCURRENCE $2 , 0 0 0 , 0 0 0
r----, D CLAIMS MADE $2 , 0 0 0 , 0 0 0
~ OCCUR AGGREGATE
I $
r------;
~ DEDUCTIBLE $
X RETENTION $0 $
A WORKERS COMPENSATION AND WC190838705 02/01/02 02/01/03 X ITWC STATU- I IOTH-
TORY LIMITS ER
EMPLOYERS' LIABILITY $100,000
E.L. EACH ACCIDENT
E.L.DISEASE-EA EMPLOYEE $100,000
E. L. DIS EASE -POLICY LIMIT $50 0 , 0 0 0
OTH ER
DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
HEURING MEADOWS - ALBERTVILLEMN
ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY:
CITY OF ALBERTVILLE; SEH
(See Attached Descriptions)
CERTIFICATE HOLDER I I ADDITIONAL INSURED: INSURER LETTER CANCELLATION
SHOU LDANYOFTHEABOVE DESCRIBED POLICIES B ECANCEL LED BEFORElH E EXPIRA TION
SEH DATETHEREOF, THEISSUING INSURER WILL~~!.1CMAIL3...0..- DAYS WRITTEN
DEBBIE GILYARD NOTICETOTH E CERTIFICATE HOLDER NAMED TO THE LEFT,:l!lWX-9U!l<<XOO~Xli4ptX
1200 25TH AVE S ~XlKHKC>>oJlrQtlXlK~JXInJl!l&9ImtlX~~J!J~Il',FXK:>>1iftlX!WX
PO BOX 1717 XElfM'XSf/nJ['ilfX
SAINT CLOUD, MN 56302-1717 AUT~:~~R EPRESENTATIVE
******~******AMENDED************ JP . ....",7' t'lo~.vil';;:yr
ACORD 25-S 797 / 0" li;l ACORD CORPORATION 1988
(I ) 1 of 3
#S73843/M73820
DLL
02/06/02 WED 11:57 [TX/RX NO 9189]
SAGfFAX 2/06/102 10:59AM CSD&Z
PAGE 2
e
e
IMPORTANT
If the certificate holder is an ADDmONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-5 (7{97) 2 of 3 # 87 38 43 /M7 38 2 0
02/06/02 WED 11:57 [TX/RX NO 9189J
The following cancellation notice supercedes the standard wording:
Should any of the above described policies be cancelled or materially
changed before the expiration date thereof, the issuing insurer will mail
30 days written notice to the certificate holder named.
AMS 25.3 (07/97) 3
of 3 #S73843/M73820
02/06/02 WED 11:57 [TX/RX NO 9189]
"'5e,
e
e
TRANSMITTAL
1200 25th Avenue South, P.O. Box 1717, SI. Cloud, MN 56302-1717
320.229.4300
800.572.0617
320.229.4301 FAX
City of Albertville
July 3, 2001
Date
A-ALBEV 0110 14
File Number and Location
TO: Linda Goeb
Client Number
RE: 2001 Heuring Meadows, Albertville, MN
We are
~ Enclosing
2 Certificate of Insurance dated 06/26/01
o Sending Under Separate Cover
~ As Requested
For your
~ Information/Records
o Action
REMARKS:
o Review
o Distribution
o Approval
o Revision and resubmittal
BY: Debbie Gilyard
c:
djg
w:\albevlO llO\corr\07030 1-city-t.doc
12100
Short Elliott Hendrickson Inc.
.
Offices located throughout the Upper Midwest
We help you plan, design, and achieve.
.
Equal Opportunity Employer
SAGfFAX 626101 11:40AM CSD&Z'-.L.LI::HIL.#; tC. tC. I
nULL'-Vl".l
PAGE 1
PRODUCER
ACOBDN CERTIFICATeoF LIABILITY INSURA E ~A~/12~/Dbi
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
MN-COMMERCIAL LINES
COBB STRECKER DUNPHY & ZIMMERMANN
150 S FIFTH ST STE 2000
MINNEAPOLIS, MN 55402
INSURERS AFFORDING COVERAGE
INSURED
MATT BULLOCK CONTRACTING
14233 42ND ST NE
ST MICHAEL, MN 55376
INSURERA CINCINNATI INSURANCE COMPANY
CO INC
INSURER B:
INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHEPOUCYPERlOOINDICATED. N01WlTHSTANDING
ANY REQUIREMENT, TERM OR CONDmON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALl THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID ClAIMS.
'~i: TYPE OF INSURANCE POllCYNUMBER P~~'f~I~FJl'oCJ~ ~~~~Z-~lrDAJ~
02/01/01 02/01/02 EACHOCCURRENCF
LIMITS
FIRE DAMAGE (Anyone fire)
M ED EXP (Anyone person)
PERSONAL &ADV INJURY
$1,000,000
$100 000
$5 000
$1 000,000
A ~NERAL LIABILITY
X COMMERCIALGENERALlIABllITY
:~ CLAIMS MADEOO OCCUR INCLUDES:
X XCU OPERATIONS OF SUBS-
-
X BROAD FORM PD CONTINGENT
GEN'L AGGREGATE LIMIT APPLI ES PER: CONTRACTUAL LIAB
I POLICY n j~gi n LOC
CPP0677450
GENERAL AGGREGATE $
PRODUCTS -COMP/OP AGG $2
000,000
A ~TOMOBILE LIABILITY
X ANY AUTO
-
CPP0677450
02/01/01 02/01/02
COMBINED SINGLE LIMIT
(Eaaccident)
$1,000,000
ALL OWNED AUTOS
BODILYINJURY
(Per person)
-
SCHEDULEDAUTOS
-
-
HIRED AUTOS
BODI L Y INJURY
(Per accident)
$
NON-OWNED AUTOS
-
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
==1 ANY AUTO
A EXCESS LIABILITY iCCC4410654
=xJ OCCUR D CLAIMS MADEl
AUTOONLY- EAACCIDENT $
OTHER THAN
AUTO ONLY:
EA ACC $
AGG $
02/01/01 02/01/02
EACH OCCURRENCE
AGGREGATE
$2,000,000
$2 , 000 , 0 0 0
, DEDUCTIBLE
}{1 RETENTION $0
A WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
WC190838704
$
$
$
02/01/01 02/0 1/02 ~jT'Z_~ntJMiLJ~W__
E.L.EACHACCIDENT $100 000
E.L.DISEASE-EAEMPLOYEE $100 000
E.L.DISEASE-POllCYLIMIT $500,000
.
OTHER
I
DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
HEURING MEADOWS - ALBERTVILLE MN
(See Attached Descriptions)
CERTIFICATE HOLDER
I I AD DITIONAL INSUR ED; INSURER LETTER:
CANCELLATION
***********AMF.NDED**************
SHOU LDANYOFTHEABOVE DESCRI BED POLICIES BECANCELLED BEFORE THE EXPIRATION
DATETHEREOF, THEISSUING INSURER WILLXJKlJWl~!.1r;MAIL3..0...... DAYS WRITTEN
NOTICETOTHE CERTIFICATE HOLDERNAMEDlOTHE LEFT,~~MlX~~KX
~XQml:Kl>>~orooKWil!lIX!n1!!1Ki9I1tOOX:Dm!Jrog:IfJ~JfXK~~
XElflJ!EXllII>>JnEK
AUTHORIZED REPRESENTATIVE
(r"" lA..l.)l. ..-....-.-.
~.J "'--' ~~1JtP
CITY OF ALBERTVILLE
5975 MAIN
ALBERTVILLE, MN 55301
ACORD 25-S (7/97) 1 of 3
#S48209/M43415
DLL CO! ACORD CORPORATION 1988
SAGIFAX 6/26/101 11:40AM CSD&Z
PAGE 2
e
e
IMPORTANT
If the certificate holder is an ADDmONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAr-JED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD25.S(7/97)2 of 3 #S48209/M43415
b6/26/2001 13:10 FAX 612 349 2490 CSDZ
- .. ~
DESCRIPTIONS (Continued from Page 1)
14]002
The following cancellation notice supercedes the standard wording:
Should any of the above described policies be cancelled or materially
changed before the expiration date thereof, the issuing insurer will mail
30 days written notice to the certificate holder named.
AMS25.3(07I97) 3 of 3 #S48209/M43415
.
3AGIFAX 626101 4:08PM CSD&Z \.,ll~:mL.*;
PAGE 1
" ACQRDw CERTIFICAT OF LIABILITY INSURA CE
PRODUCER
MN-COMMERCIAL LINES
COBB STRECKER DUNPHY & ZIMMERMANN
150 S FIFTH ST STE 2000
MINNEAPOLIS, MN 55402
DATE(MMfDDfWl
06/26/01
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
INSURED
MATT BULLOCK CONTRACTING CO INC
14233 42ND ST NE
ST MICHAEL, MN 55376
INSURER A: CINCINNATI INSURANCE COMPANY
INSURER B:
INSURER C:
INSURER 0:
INSURER E:
COVERAGES
THE POLIOESOFINSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHEPOLICYPERIOOINDICATED, NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDIllON OF ANY CONTPJ\CT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAJN1 THE INSURANCE AFFORDED BY THE POUOES DE~BED HEREIN IS SUBJECT TO ALL THE TERMS1 EXCLUSIONS AND CONDIllONS OF SUCH
POLIOES, AGGREGA.TE L1MrrS SHOWN MAY HAVE BEEN REDUCED BY PAJD CLAJMS.
INSR lYPEOF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRA J:
LTR DATEIMMJDDIYYl DATEIMM/DD LIMITS
A GENERAL L1ABILllY CPP0677450 02/01/01 02/01/02 EACH OCCURRENCE $1, 000,000
-
X COM MERCIALGENERAL LIABILITY FIR E DAMAG E (Anyone lire) $100,000
I CLAIMS MADE~ OCCUR INCLUDES: MED EXP (Anyone person) $5,000
X XCU OPERATIONS OF SUBS- PERSONAL & ADV INJURY $1,000,000
X BROAD FORM PD CONTINGENT GENERAL AGGREGATE $
f--
GENlAGGREGATE LIMIT APPLIES PER: CONTRACTUAL LIAB PRODUCTS -COMP!OP AGG $2 , 0 0 0 , 0 00
n ,nPRO- n
POLICY JECT LOC
A AUTOMOBILE LlABILllY CPP0677450 02/01/01 02/01/02 COMBINED SINGLE LIMIT
- $l,000,000
X ANY AUTO (Eaaccidenl)
-
ALL OWNED AUTOS BODILYINJURY
- $
SCHEDULED AUTOS (Per person)
~
HIRED AUTOS BODILYINJURY
c--- $
NON -OWN ED AUTOS (Per accident)
c---
(r~1 e'M;IU~llIl
GARAGE lIABllIlY
ANY AUTO
AUTO ON L Y - EA ACCI DENT $
OTH ER THAN EA ACC $
AUTO ON L Y: AGG $
02/01/01 02/01/02 EACH OCCURRENCE
A EXCESSLIABllIlY CCC4410654
X OCCUR D CLAIMS MADE
AGGREGATE
DEDUCTIBLE
X RETENTION. $0
A WORKERS COMPENSATION AND WC 19 0 8 38704
EMPLOYERS'LIABllIlY
$
$
$
OTH-
ER
E,L, EACH ACCIDENT $100 000
E.L.DISEASE-EAEMPLOYEE $100 000
E,L.DISEASE-POLlCYLlMIT $500 000
OTH ER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
HEURING MEADOWS - ALBERTVILLE MN
The following cancellation notice supercedes the standard wording:
(See Attached Descriptions)
CERTIFICATE HOLDER
ADDmONAL INSURED; INSURER LETTER
CANCELLATION
SEH
DEB
1200 25TH AVE S
PO BOX 1717
SAINT CLOUD, MN 56302-1717
****** **AMENDED****************
ACOOD25.S(7/9~1 of 3 #S48213/M43415
SHOULDANYOFTHEABOVE DESCRI BEDPOlICI ES BECANCELLED BEFORETH E EXPIRATION
DATETHEREOF, THEISSUING INSURER WI LLXOOI<<MMAI L3..(L DAYS WRITTEN
NOTICETOTHE CERTIFICATE HOLDER NAMED TO THE LEFT,~UJX<<R~~DtX
mgl~K~OOn~gin~EI\1lIXK~Hm
Xaflm>>JVEX
AUTHORIZE REPRESENTATIVE
I: t'. 'yitn
DLL ~ ACORD CORPORATION 1988
,
SAGIFAX 626 101 4:06PM CSD&Z
PAGE 2
IMPORTANT
~ the certfficate hclder is an ADDmONAL INSURED, the pdicy(ies) must be endorsed. A statement
on ~is certfficate does not confer rights to ~e certificate hclder in lieu of such endorsement(s).
~ SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain pdicies may
require an endorsement. A statement on ~is certificate does not confer rights to ~e certificate
hclder in lieu of such endorsement(s).
DISCLAIMER
The Certfficate of Insurance on the reverse side of this form does not constITute a contract between
~e issuing insurer(s), authorized representat~e or producer, and the certificate holder, nor does IT
affirmat~ely or negat~ely amend, extend or alter the coverage afforded by the pdicies listed thereon.
e
tit
ACORD25.S(71971? nf l H~4R?ll/M4l41 ~
.
SAGIFAX 626 101 4:0BPM CSD&Z
PAGE 3
....... ...."........... ....
..."...,.............
......................
...........................
. . . . . . . . . . . . . . . .
. , . . . . . . . . . . . . . . . . . . . . . .
........................
. ........ .".
................... ........................................................,............................ ..........................................................................
..................... ..................................,................................................... ...............................,........_.................d.....'.......
. ...... . .
. . . . . . . . . . . . . . . . . . . . . .
..."................
. . . . . . . . . . . . . , . . . . . . . .
............,........
.................................
.....P..........................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. ..........."..... ,...
...................................
.......".........."...............
..........................-........
................p.................
. .. . . . . . . . . . .
....,.........."...."......
,............................
. , . . . . . . . , . . . . , . , , , . . , . , , . , , ,
,......"............,.......
. . . , , , . . , , . . - . . . . . . . . . . . . . . . .
....................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
............,.......................
.......................... ..
............... .
Should any of the above described policies be cancelled or materially
changed before the expiration date thereof, the issuing insurer will mail
30 days written notice to the certificate holder named.
e
e
AMS25.3(07/9~ 3 of 3 ~S48213/M43415
.
.
.
m!!!!o!!!!.D!!
1900 SOUTH 18TH A VENUE. WEST BEND, WI 53095
CUSTOMER~. 0110099964
If( U~
..
POLICY NUMBER: CPO 0314201 01
RENEWAL
COMMERCIAL GENERAL LIABILITY ADDITIONAL INTEREST
CITY OF ALBERTVILLE
5975 MAIN AVE, NE, PO BOX 9
ALBERTVILLE, MN 55301
FORM WB1450
APPLIES
ALL OTHERS-NOC
ADDITIONAL INSURED
INSURED: LEUER-MUNSTERTEIGER
PROPER fIES, INC
100 E CENTRAL PO BOX 340
ST MICHAEL, MN 55376
AGENCY: ZACHMAN INSURANCE AGENCY INC
22-565
POLICY PERIOD FROM: MAY 08, 2001 TO: MAY 08, 2002
ISSUED 03/26/01
ADDL INTEREST COPY
.
.
.
m !!!OMI!!!!..~
1900 SOUTH 18TH A VENUE. WEST BEND. WI 53095
CUSTOME~O. 0110099964
f{ Ht3
POLICY NUMBER: CPO 0314201 01
RENEWAL
COMMERCIAL GENERAL LIABILITY ADDITIONAL INTEREST
BUILDERS MORTGAGEE CO, LLC
646 E RIVER RD
ANOKA, MN 55303
FORM WB1450
APPLIES
ALL OTHERS-NOC
ADDITIONAL INSURED
INSURED: LEUER-MUNSTERTEIGER
PROPERTIES, INC
100 E CENTRAL PO BOX 340
ST MICHAEL, MN 55376
AGENCY: ZACHMAN INSURANCE AGENCY INC
22-565
POLICY PERIOD FROM: MAY 08, 2001 TO: MAY 08, 2002
ISSUED 03/26/01
ADDL INTEREST COPY