2002-04-01 Insurance Certificate
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TRANSMITTAL
1200 25th Avenue South, POBox 1717, St Cloud, MN 56302 1717
320 229 4300
8005720617
320 229 4301 FAX
TO Lmda Goeb
CIty of AlbervIlle
Apnl 1, 2002
Date
A-ALBEV 0002 14
FIle Number and LocatIon
Ghent Number
RE 2000 Albert VIllas, AlbertvIlle, MN
Insurance
We are
!81 Enclosmg
1 CertIfIcate of Insurance, 03/22/02
o Sendmg Under Separate Cover
o As Requested
For your
o Information/Records
o Action
REMARKS
o ReVIew
o Dlstnbutlon
!81 Approval
o RevIsion and resubmJttal
BY DebbIe GIlyard
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w lalbev\OOO2\corr\t cIty lnsure 040102 doc
12100
Short Elliott Hendrickson Inc
.
Offices located throughout the Upper Midwest
We help you plan, deszgn, and achzeve
.
Equal Opportunity Employer
ACORD",
Cllent 14847 KUEUN
CERTIFICA. OF LIABILITY INSURelCE
DATE (MM/DD1YY)
03/22/02
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
J A PRICE AGENCY, INC
6640 Shady Oak Road
SUlte 500
Eden Pralrle, MN 55344
INSURERS AFFORDING COVERAGE
INSURER A Western Natlonal Mutual Insurance
INSURED
Kuechle Underground, Inc.
20 Maln Street
POBox 509
Klmball, MN 55353
COVERAGES
INSURER B
INSURER C
INSURER D
INSURER E
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 Pgk!fJ(~~r~J~ POLlCT ~XPIRATJ~ LIMITS
LTR DATE MMIDD/
A GENERAL LIABILITY CP300001273 03/24/02 03/24/03 EACH OCCURRENCE $1.000.000
-
X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire $100 000
l CLAIMS MADE[K] OCCUR ME D EXP (Anyone person) $5.000
- PERSONAL & ADV INJURY $1. 000.000
- GENERAL AGGREGATE $2 . 0 0 0 . 000
~'L AGGR~~ LIMIT AI~.'-~rPER PRODUCTS COM PlOP AGG $2.000.000
POLICY X ~~gT LOC
A ~TOMOBILE LIABILITY CA300001536 03/24/02 03/24/03 COMBINED SINGLE LIMIT
II ANY AUTO (Ea aCCident) $1,000,000
- ALL OWNED AUTOS BODIL Y INJURY
$
SCHEDULED AUTOS (Per person)
-
HIRED AUTOS BODIL Y INJURY
- $
NON OWNED AUTOS (per aCCIdent)
-
- PROPERTY DAMAGE $
(Per aCCident)
~RAGE LIABILITY AUTO ONL Y EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONL Y AGG $
A EXCESS LIABILITY CU30000584 03/24/02 03/24/03 EACH OCCURRENCE $2.000.000
rn OCCUR D CLAIMS MADE AGGREGATE $2. 000. 000
$
~ DEDUCTIBLE $
X RETENTION $10 000 $
A WORKERS COMPENSATION AND WC300001273 03/24/02 03/24/03 X 1-n;~nfJX-sl jOll;'
EMPLOYERS' LIABILITY $100,000
E L EACH ACCIDENT
E L DISEASE EAEMPLOYEE $100,000
E L DISEASE POLICY L1MI $500.000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONSADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Certlflcate holder has been added to the general llablllty POllCY as an
addltlonal lnsured as per the Addltlonal Insured - Owners, Lessees or
Contractors - Automatlc Status When Requlred ln Constructlon Agreement
Wlth You endorsement Also named as Addltlonal Insured on the general
(See Attached Descrlptlons)
CERTIFICATE HOLDER I I ADDmONALlNSURED INSURER LETTER: CANCELLATION
SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
SEH DATE THEREOF THE ISSUING INSURER WILLENDEAVORTOMAIL3.ll- DAYS WRITTEN
1200 25th Avenue South NOTICETOTHE CERTIFICATE HOLDER NAMED TO THE LEFT BUTFAILURE TO DO SO SHALL
P 0 Box 1717 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE I NSURER, ITS AGENTS OR
Salnt Cloud, MN 56302-1717 REPRESENTATIVES
AUTHORIZED REPRESEIf:TIVE
I ClrLt_ . fr~ -' ^ .n~
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ACORD 25-S (7/97)1 of 3
#M9186
JMK @ ACORD CORPORATION 1988
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IMPORTANT
If the certificate holder IS an ADDITIONAL INSURED, the pollcY(les) 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 #M9186