2001-06-21 Revised Cert of Ins.
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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
City of Albertville
June 21, 2001
Date
A-ALBEV 0109.00 14
File Number and Location
TO: Linda Goeb
Client Number
RE: 2000 Albert Villas 3rd Addition
We are
181 Enclosing 0 Sending Under Separate Cover
1 Revised Certificate of Insurance dated 04/16/01
181 As Requested
For your
181 Information/Records
o Action
REMARKS:
o Review
o Distribution
o Approval
o Revision and resubmittal
BY: Debbie Gilyard
djg
w:\albevlO 1 09lcorrl0621 0 l-goeb-t.doc
4/00
Short Elliott Hendrickson Inc.
.
Offices located throughout the Upper Midwest
We help YOUplan, design, cmd achieve
.
Equal Opportunity Employer
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CERTIFIC
14847 KUEUN
OF LIABILITY INSU.NCE
DATE (MMIDD/YY)
04/16/01
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.
PRODUCER
J. A. PRICE AGENCYt INC.
6640 Shady Oak Road
Suite 500
Eden prairiet MN 55344
INSURED
Kuechle Undergroundt Inc.
20 Main Street
P.O. Box 509
Kimballt MN 55353
COVERAGES
INSURERS AFFORDING COVERAGE
INSURERA:Western National Mutual Insurance
INSURER B:
INSURER C:
INSURER 0:
INSURER E:
THE POUCIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POUCIES. AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRI TYPE OF INSURANCE POLICY NUMBER POLICY EFFTtfJJ~ P?,'i~ (~~~AJ)~ LIMITS
TR
I 03/24/01 03/24/02 I EACH OCCURRENCE
A ~NERALLlABILITY CP300001273 $1 000 000
X i COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any one fire~ $10 0 . 0 0 0
h I I CLAIMS MADE[X] OCCUR I MED EXP (Any one person) 1$5 000
~PD Ded: 1,000 I I PERSONAL & ADV INJURY $1 . 000 , 000
i I I GENERAL AGGREGATE $2 , 000 , 000
~'L AGGR~~ LIMIT APf=iSPER: I I PRODUCTS-COMP/OP AGGI $2 , 000 , 000
, '. I
I X i POLICY I I ~~gT I LOC . I I
A I AUTOMOBILE LIABILITY CA300001536 03/24/01 03/24/02 I
rxl ANY AUTO COMBINED SINGLE LIMIT i $1 000 000
(Ea accident) t,
! i
I I ALL OWNED AUTOS BODIL Y INJURY
~ SCHEDULED AUTOS (Per person) $
~ HIRED AUTOS I BODILY INJURY 1$
LKJ NON-OWNED AUTOS (Per accident)
~ I PROPERTY DAMAGE I
i i (Per accident) $
I GARAGE LIABILITY AUTO ONL Y - EA ACCI DENT $
R ANY AUTO OTHER THAN EAACC i $
AUTO ONLY: AGG i $
A ~ESS LIABILITY CU30000584 03/24/01 03/24/02 EACH OCCURRENCE $2 . 000 . 000
~ OCCUR D CLAIMS MADE AGGREGATE $2 . 000 . 000
$
~ DEDUCTIBLE $
X RETENTION $10 . 000 $
WORKERS COMPENSATION AND ! [T,,;;g~n.1~~ I IOJ~-
EMPLOYERS' LIABILITY I
I ~ACH ACCIDENT I $
E.L.DISEASE-EAEMPLOYES $
E.L. DISEASE-POLICY L1MI~ $
A I OTHER Inland IM300001558 03/24/01 03/24/02 100,000/For Each
rr: . I Jobsite Location
arlne-
Installation Floater I
DESCRIPTION OF OPERATlONS/LOCATIONS/VEHICLES/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 ADDmONALIN"" "" .,"""'........=... ATION
~~~ n w bcr1. .~ 1LnlOFTHEABOVE DESCRIBED POUCIES eECANCELLED BEFORETHEEXPIRATlON
SEH.RCM In i-:A-h:, 'H REOF,THE ISSUING INSURERWILLENDEAVORTOMAIL3-0.- DAYS WRITTEN
. "
1200 25th Avenue South i, ~ NOTlC~TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT, BUTFAlLURE TO DO SO SHALL
P.O. Box 1717 , JUN 2 1 2001 IMPOSE NO OBLIGATION OR LIABILITY OF ANYKIND UPON THE INSURER,ITSAGENTS OR
Saint Cloud, MN 56302-1 1 7 REPRESENTATIVES.
AUTHORIZED REPRESEkl::TIVE
I C'\. i.. 'I:tt-~ ^" 01\ ...J
ACORD 25-S (7/97)1 of 3 #M811:J . LLLlU I t. t1LNUHI.;r~/JON JMK @ ACORD CORPORATION 1988
SAINT CLOUD, MN
DE
IPTIONS (Continued from
.~ :'-~
ge 1)
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 0 f 3 #M8119
tit
.
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 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 #M8119