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<br /> Insurance Certificate
<br /> Documentation of current insurance coverage and limits,including professional liability insurance is available upon
<br /> request. If you have any questions please contact Brian Tomm,Bolton&Menk's Business Manager, at(507) 625-4171.
<br /> /_"N BOLTO-1 OP ID:MP
<br /> ,4��°® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/VVVV)
<br /> 05/07/13
<br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
<br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
<br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
<br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br /> certificate holder in lieu of such endorsement(s).
<br /> CONTACT
<br /> PRODUCER 507-388-2010 NAME:
<br /> Brown&Brown of MN/Mkto 507-388-5492 PHONE FAx
<br /> 530 W Pleasant St A/C No Ext: A/C,No):
<br /> Mankato,MN 56001 E-MAIL
<br /> Mary E.Fortner,CISR ADDRESS:
<br /> INSURERS)AFFORDING COVERAGE NAIC#
<br /> INSURER A:Westfield Insurance Company 24112
<br /> INSURED Bolton and Menk,Inc. INSURERB:Westfield National Insurance 24120
<br /> 1960 Premier or
<br /> Mankato,MN 56001 INSURER C:
<br /> INSURER D:
<br /> INSURER E:
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br /> INSR TYPE OF INSURANCE POLICY EFF POLICY EXP
<br /> LTR INSR WVD POLICVNUMBER MM/DD/VVVV I (MM/DD/YYYYI LIMITS
<br /> GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> Am
<br /> • X COMMERCIALGENERALLIABILITY CMM 3 406 737 07/01/12 07/01/13 PREMISES Eaoccunence $ 1,000,000
<br /> CLAIMS-MADE OCCUR MED EXP(Any one person) $ 10,000
<br /> • X XCU Coverage BLKT CONTRACTUAL LIAB 07/01/12 07/01/13 PERSONAL&ADV INJURY $ 1,000,000
<br /> • X Blkt Addllnsured &BLKT WAIVER SUBROGATION 07/01/12 07/01/13 GENERAL AGGREGATE $ 2,000,000
<br /> GEML AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000
<br /> POLICY X PRO- LOC Emp Ben. $ 1,000,000
<br /> AUTOMOBILE LIABILITY Ea aBc EDtSINGLE LIMIT $ 1,000,006
<br /> A X ANY AUTO CMM 3 406 737 07/01/12 07/01/13 BODILY INJURY(Per person) $
<br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS AUTOS
<br /> NON-OWNED PROPERTVDAMAGE $
<br /> HIRED AUTOS AUTOS Per accident
<br /> X Blkt Waive of Subro $
<br /> UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000
<br /> A X EXCESS LAB CLAIMS-MADE CMM 3 406 737 07/01/12 07/01/13 AGGREGATE $ 5,000,000
<br /> DIED X RETENTION$ -0' 1$
<br /> WORKERS COMPENSATION X WCSTATU- OTH-
<br /> AND EMPLOYERS'LIABILITY TORY LIMITS ER
<br /> B AN PROPRIETOR/PARTNER/EXECUTIVE V� N/A WCP S DBD 987 07/01/12 07/01/13 E.L.EACH ACCIDENT $ 500,000
<br /> (Mandatory oMEMNHREXCLUDED? BLANKET WAIVER OF SUBR 500,000
<br /> ( ry in ) E.L.DISEASE-EA EMPLOYEE$
<br /> yes, under
<br /> DESCRIPTI ON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
<br /> B Professional Liab AFE 11 401 97 18 12131/12 12131/13 Claim 5,000,000
<br /> Errors&Omissions RETROACTIVE DATE 12/31/97 Aggregate 5,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> CITYELK
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> City of Elk River ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Justin Femrite
<br /> City Engineer AUTHORIZED REPRESENTATIVE
<br /> 13065 Elk River,Orono MIN 553way � A�
<br /> Elk River,MN 55330 �l�"4
<br /> ©1988-2010 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
<br /> Wastewater Treatment Facility Improvements I City of Elk River, Minnesota 1
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