2002-04-01 Cert of Insurance
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TRANSMITTAL
1200 25th Avenue South, P.O. Box 1717, SI. Cloud, MN 56302-1717
320.229.4300
800.572.0617
320.229.4301 FAX
TO: Linda Goeb
City of Albertville
April 1, 2002
Date
A-ALBEV 0109.00 14
File Number and Location
Client Number
RE: 2000 Albert Villas 3rd Addition
We are
IZI Enclosing
1 Certificate of Insurance, 03/22/02
o Sending Under Separate Cover
IZI As Requested
For your
IZI Information/Records
o Action
o Review
o Distribution
o Approval
o Revision and resubmittal
REMARKS:
BY: Debbie Gilyard
djg
w:lalbevlO l09lcorrlt-city insure-04O 1 02.doc
4/00
Short Elliott Hendrickson Inc.
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Offices located throughout the Upper Midwest
We help YOIl plan, design, and achieoe
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Equal Opportunity Employer
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Client:lt: 14847 KUEUN
ACORD"" CERTIFICAe: OF LIABILITY INSU.NCE 1 DATE (MMIDD/YY)
03/22/02
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
J. A. PRICE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
6640 Shady Oak Road HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Suite 500
Eden Prairie, MN 55344 INSURERS AFFORDING COVERAGE
INSURED INSURERA:Western National Mutual Insurance
Kuechle Underground, Inc. INSURER B:
20 Main Street INSURER C:
P.O. Box 509 .-
INSURER D:
KimbaLt, MN 55353
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 CONDfflON 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 CONDfflONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE POLICY NUMBER POLlCYJFFECTNmPOLlC\ ~XPIRATI9~ LIMITS
LTR DATE MMIDD/ DATE MMIDD/Y
CP300001273 03/24/02 I 03/24/03 $1.000.000
A GENERAL LIABILITY EACH OCCURRENCE
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lL ~MERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire $100 000
CLAIMS MADE[K] OCCUR ME D EXP (Anyone person) $S.OOO
~ PERSONAL & ADV INJURY $1.000.000
~ GENERAL AGGREGATE $2.000.000
~'L AGGR~~L1MIT APnSPER: PRODUCTS-COMP/OP AGG $2. 000. 000
I POLICY X j~g;: LOC
A ~TOMOBILE LIABILITY CA300001536 03/24/02 03/24/03 COMBINED SINGLE LIMIT $1,000,000
II ANY AUTO (Ea accident)
- ALL OWNED AUTOS BODIL Y INJURY _I $
- SCHEDULED AUTOS
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-- HIRED AUTOS BODIL Y INJURY
~~ NON-OWNED AUTOS (Per accident) -+
- PROPERTY DAMAGE i $
(Per accident) -
RRAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONL Y: AGG $
A EXCESS LIABILITY CU30000584 03/24/02 03/24/03 ~ACH OCCURRENCE $2 . 000 000
CZJ OCCUR D CLAIMS MADE AGGREGATE _1:2,000,000
8 DEDUCTIBLE -1$
X RETENTION $10 000 i$
A WORKERS COMPENSATION AND WC300001273 03/24/02 03/24/03 X I,WCSTATU-! JOJ~-I
TO_RY LIMITS
EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT 1$100,000
E.L.DISEAS~-EAEMPLOy~~r$l 00, 000
I E.L.DISEASE-PO~ICYLlM-;:;r$500, 000
OTHER 1
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DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Certificate holder has been added to the general liability policy as an
additional insured as per the Additional Insured - Owners, Lessees or
Contractors - Automatic Status When Required in Construction Agreement
With You endorsement. City of Albertville is also named as Additional
(See Attached Descriptions)
CERTIFICATE HOLDER I I ADDmONALlNSURED'INSURER lETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBEDPOUCIES BE CANCELLED BEFORE THE EXPIRATION
SEH DATE THEREOF,THE ISSUING INSURER WILLENDEAVORTO MAIL3...0....- DAYS WRITTEN
1200 25th Avenue South NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUTFAILURE TO DO SO SHALL
P.O. Box 1717 IMPOSE NO OBLIGATION OR L1ABI L1TY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Saint Cloud, MN 56302-1717 REPRESENTATIVES.
AUTHORIZfr~PRESEI!:TIVE
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ACORD 25-S (7/97)1 of 3
#M9186
JMK @ ACORD CORPORATION 1988
DE.IPTIONS (Continued from ege 1)
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Insured on the general liability.
RE: Albert Villas, 3rd Addition, Albertville, MN, SEH File #A-ALBEV 010914
* REVISED CANCELLATION CLAUSE -
Should any of the above described policies be materially changed,
suspended, or cancelled before the expiration date there of or fail
to be renewed upon their expiration, the issuing company will mail
30 days prior written notice to the named certificate holder.
AMS 25.3 (07/97) 3
of 3 #M9186
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IMPORTANT
If the certificate holder is an ADDITIONAL 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 SUBROGA TrON 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-S (7/97)2 of 3 #M9186