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<br />Insurance Certificate
<br />BOLTO-1OP ID: MP
<br />DATE (MM/DD/YYYY)
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />08/13/2018
<br />THISCERTIFICATEISISSUEDASAMATTEROFINFORMATIONONLYANDCONFERSNORIGHTSUPONTHECERTIFICATEHOLDER.THIS
<br />CERTIFICATEDOESNOTAFFIRMATIVELYORNEGATIVELYAMEND,EXTENDORALTERTHECOVERAGEAFFORDEDBYTHEPOLICIES
<br />BELOW.THISCERTIFICATEOFINSURANCEDOESNOTCONSTITUTEACONTRACTBETWEENTHEISSUINGINSURER(S),AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT:IfthecertificateholderisanADDITIONALINSURED,thepolicy(ies)musthaveADDITIONALINSUREDprovisionsorbeendorsed.
<br />IfSUBROGATIONISWAIVED,subjecttothetermsandconditionsofthepolicy,certainpoliciesmayrequireanendorsement.Astatementon
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />CONTACT
<br />507-388-2010Mary Portner
<br />PRODUCER
<br />NAME:
<br />Brown & Brown of MN/Mkto
<br />PHONEFAX
<br />507-388-2010507-388-5492
<br />(A/C, No, Ext):(A/C, No):
<br />530 W Pleasant St
<br />E-MAIL
<br />Mankato, MN 56001
<br />mportner@bbmankato.com
<br />ADDRESS:
<br />Mary E. Portner
<br />INSURER(S) AFFORDING COVERAGENAIC #
<br />Westfield Insurance Company24112
<br />INSURER A :
<br />Bolton and Menk, Inc.
<br />Westfield National Ins Co24120
<br />INSURED
<br />INSURER B :
<br />1960 Premier Dr
<br />Continental Casualty Co20443
<br />INSURER C :
<br />Mankato, MN 56001
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />COVERAGESCERTIFICATE NUMBER:REVISION NUMBER:
<br />THISISTOCERTIFYTHATTHEPOLICIESOFINSURANCELISTEDBELOWHAVEBEENISSUEDTOTHEINSUREDNAMEDABOVEFORTHEPOLICYPERIOD
<br />INDICATED.NOTWITHSTANDINGANYREQUIREMENT,TERMORCONDITIONOFANYCONTRACTOROTHERDOCUMENTWITHRESPECTTOWHICHTHIS
<br />CERTIFICATEMAYBEISSUEDORMAYPERTAIN,THEINSURANCEAFFORDEDBYTHEPOLICIESDESCRIBEDHEREINISSUBJECTTOALLTHETERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSRADDLSUBRPOLICY EFFPOLICY EXP
<br />TYPE OF INSURANCEPOLICY NUMBERLIMITS
<br />LTRINSDWVD(MM/DD/YYYY)(MM/DD/YYYY)
<br />2,000,000
<br />A COMMERCIAL GENERAL LIABILITY
<br />X
<br />EACH OCCURRENCE$
<br />DAMAGE TO RENTED
<br />1,000,000
<br />CLAIMS-MADEOCCUR
<br />X
<br />CMM 3 406 73701/01/201801/01/2019
<br />$
<br />XX PREMISES (Ea occurrence)
<br />XCU Coverage10,000
<br />A
<br />X
<br />BLKT CONTRACTUAL LIAB
<br />MED EXP (Any one person)$
<br />Blkt AI & Waiv of2,000,000
<br />A
<br />X
<br />& BLKT ADD'L INSURED
<br />PERSONAL & ADV INJURY$
<br />4,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$
<br />PRO-
<br />4,000,000
<br />X
<br />POLICYLOC
<br />PRODUCTS - COMP/OP AGG$
<br />JECT
<br />Emp Ben.1M/2M
<br />OTHER:$
<br />COMBINED SINGLE LIMIT
<br />1,000,000
<br />A
<br />AUTOMOBILE LIABILITY
<br />$
<br />(Ea accident)
<br />X
<br />ANY AUTO CMM 3 406 73701/01/201801/01/2019
<br />BODILY INJURY (Per person)$
<br />XX
<br />OWNEDSCHEDULED
<br />AUTOS ONLYAUTOSBODILY INJURY (Per accident)$
<br />PROPERTY DAMAGE
<br />HIREDNON-OWNED
<br />XX
<br />(Per accident)$
<br />AUTOS ONLYAUTOS ONLY
<br />Blkt Waive
<br />of Subro
<br />X
<br />$
<br />10,000,000
<br />A
<br />X
<br />UMBRELLA LIAB OCCUR
<br />EACH OCCURRENCE$
<br />CMM 3 406 73701/01/201801/01/2019
<br />10,000,000
<br />EXCESS LIAB CLAIMS-MADE
<br />XX
<br />AGGREGATE$
<br />-0-
<br />X
<br />DEDRETENTION$
<br />$
<br />PEROTH-
<br />WORKERS COMPENSATION
<br />B
<br />X
<br />STATUTEER
<br />AND EMPLOYERS' LIABILITY
<br />Y / N
<br />WCP 867764501/01/201801/01/2019
<br />1,000,000
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />E.L. EACH ACCIDENT$
<br />N / A
<br />N
<br />OFFICER/MEMBER EXCLUDED?
<br />BLANKET WAIVER OF SUBR
<br />1,000,000
<br />(Mandatory in NH)
<br />E.L. DISEASE - EA EMPLOYEE$
<br />If yes, describe under
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS belowE.L. DISEASE - POLICY LIMIT$
<br />Professional LiabiAFE 11 401 97 1812/31/201712/31/2018
<br />Claim5,000,000
<br />C
<br />E&O/Ded $50,000RETROACTIVE DATE 12/31/97
<br />Aggregate10,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />City of Elk River is added as an additional insured under the general, auto
<br />& excess liability. Coverage provided is primary & non-contributory.
<br />Waivers of subrogation in favor of the City of Elk River apply to all
<br />policies except the Professional Liability & work comp.
<br />CERTIFICATE HOLDERCANCELLATION
<br />CITYELK
<br />SHOULDANYOFTHEABOVEDESCRIBEDPOLICIESBECANCELLEDBEFORE
<br />THEEXPIRATIONDATETHEREOF,NOTICEWILLBEDELIVEREDIN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />City of Elk River
<br />13065 Orono Parkway
<br />AUTHORIZED REPRESENTATIVE
<br />Elk River, MN 55330
<br />ACORD 25 (2016/03)© 1988-2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />2019 Street Improvements | Elk River, Minnesota
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