2004-02-23 Cert of Insurance
Jt..
SEH
TRANSMITTAL
To: Larry Kruse
City of Albertville
Date:
February 23, 2004
A-ALBEV 0110 7
SEH File No.:
Client No.:
N/A
Re: Heuring Meadows, Albertville, MN
We are:
181 Enclosing 0 Sending under separate cover 0 Sending as requested
1 Matt Bullock Contracting Co., Inc. Certification of Insurance, 02/04/04
For your:
181 Information/Records
o Action
Remarks:
o Review and comment
o Distribution
o Approval
o Revision and resubmittal
By: Debbie Gilyard
c:
djg
u:\a\albevlOllOOO\corr\t-city insure-022304,doc
1/04
Short Elliott Hendrickson Inc., 1200 25th Avenue South, P,O, Box 1717, St Cloud, MN 56302-1717
SEH is an equal opportunity employer I www.sehinc.comI320.229.4300 I 800,572_0617 I 320,229.4301 fax
,-
Client#: 227
BULLCONI
PRODUCER
MN-COMMERCIAL LINES
COBB STRECKER DUNPHY & ZIMMERMANN
150 S FIFTH ST STE 2000
MINNEAPOLIS, MN 55402
DATE (MM/DDIYYYY)
02/04/04
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.
ACOfiDTM' CERTIFICATE OF LIABILITY INSURANCE
INSURED
INSURERS AFFORDING COVERAGE
INSURER A: CINCINNATI INSURANCE COMPANY
MATT BULLOCK CONTRACTING CO INC
14233 42ND ST NE
ST MICHAEL, MN 55376
INSURER B:
INSURER C:
INSURER D:
INSURER E:
NAIC#
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.
L TR NSRI TYPE OF INSURANCE POLICY NUMBER PJ>}+~~J~;6g~~\E Pg~~J ,~X~~J~N LIMITS
A GENERAL LIABILITY CPP0677450 02/01/04 02/01/05
-
X COMMERCIAL GENERAL LIABILITY
I CLAIMS MADE [Xl OCCUR INCLUDES:
1L XCU OPERATIONS OF
X BROAD FORM PD SUBS-CONTINGENT
~'L AGGRE~E LIMIT APAS PER: CONTRACTUAL L1AB
POLICY X jr8i LOC
A ~TOMOBILE LIABILITY CPP0677450 02/01/04 02/01/05
X ANY AUTO
-
ALL OWNED AUTOS
-
_ SCHEDULED AUTOS
~ HIRED AUTOS
X NON-OWNED AUTOS
-
~RAGE LIABILITY
ANY AUTO
A EXCESS/UMBRELLA LIABILITY CPP0677 450 02/01/04 02/01/05
~ OCCUR D CLAIMS MADE
~ DEDUCTIBLE
X RETENTION $0
A WORKERS COMPENSATION AND WC190838706 02/01104 02/01/05
EMPLOYERS' L1AB!L1TY EXEC OFFICERS INCL
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
OTHER
EACH OCCURRENCE
~~~~~H9E~~~~~Rence )
MED EXP (Anyone person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
(Per accident)
AUTO ONLY - EA ACCIDENT
OTHER THAN
AUTO ONLY:
EACH OCCURRENCE
AGGREGATE
X I WC STATU- I IOTH-
T"RY LIMIT" I I ER
$1 000.000
$100,000
$5 000
$1,000 000
$2 000.000
$2,000,000
$1,000,000
$
$
$
EA ACC
AGG
$
$
$
$2 000 000
$2.000 000
$
$
$
E.L. EACH ACCIDEf.lT s100,000
E.L. DISEASE - EA EMPLOYEE $100,000
E.L. DISFASE - POLICY LIMIT $500,000
Orn@Q~O wrn~
~ FEB 0 6 2004
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
HEURING MEADOWS - ALBERTVILLE MN
L.<
--"
! t.~_._. -,_.--.~~-.__.-
i SHORT. ELUme HENDRICKSON
L__SAI~n CL~VP_:-l\!~_
ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY:
CITY OF ALBERTVILLE; SEH
(See Attached Descriptions)
CERTIFICATE HOLDER
CANCELLATION
SEH
DEBBIE GILYARD
1200 25TH AVE S
PO BOX 1717
SAINT CLOUD, MN 56302-1717
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF. THE ISSUING INSURER WILL X~KX~ MAIL -3!L DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.~)(J(~n~wx
~K~.~~~~~~~~~K.~~X~X~~~~X~RXXX
xJt86e5x~n
AUTHORIZED REPRESENTATIVE
ACORD 25 (2001/08) 1 of 3
#S 137 432/M 137373
@ ACORD CORPORATION 1988
"
DESCRIPTIONS (Continued from Page 1)
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 (2001/08)
3 of 3
#S137432/M137373