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ACoRo® CERTIFICATE OF LIABILITY INSURANCE (MM/DD/ <br /> DD/s/zo1YYYY) <br /> 11/z9 <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 have ADDITIONAL INSURED provisions or be endorsed. <br /> If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT <br /> NAME: Matthew Cartier <br /> Cartier Agency, Inc. PHONE FAX <br /> 2631 W. Superior St AIC No Ext: (218) 727-5992 A/C No: <br /> E-MAIL <br /> ADDRESS: ahess@caduluth.com <br /> Duluth MN 55816 <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURERA:Western National 15377 <br /> INSURED (651) 481-1190 INSURERB:American Interstate Insurance 31895 <br /> Rink-Tec International Inc. <br /> INSURER C: <br /> 3485 Willow Lake Blvd INSURER D: <br /> Suite #500 <br /> Vadnais Heights MN 55110 INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER:cert ID 4808 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS <br /> LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY <br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 <br /> DA AGTE <br /> CLAIMS-MADE Ix I OCCUR CPP0020756 18 02/01/2019 02/01/2020 1REMM SEE SOEa.N. ,D.nce $ 1,000,000 <br /> MED EXP(Any one person) $ 10,000 <br /> PERSONAL&ADV INJURY $ 11000,000 <br /> GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 <br /> POLICY JjRO- <br /> ECT [::] LOC PRODUCTS-COMP/OPAGG $ 2,000,000 <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> Ea accident 1,000,000 <br /> A X ANY AUTO CPP0020736 18 02/01/2019 02/01/2020 BODILY INJURY(Per person) $ <br /> OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS ONLY AUTOS <br /> HIRED NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS ONLY AUTOS ONLY Per accident <br /> A X UMBRELLA LIAB X OCCUR UMB0011474 18 02/01/2019 02/01/2020 EACH OCCURRENCE $ 5,000,000 <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 <br /> DED X RETENTION$ 10,000 Pers/Adv Injury $ 5,000,000 <br /> B <br /> WORKERS EMPLOYCOMPENSATION EMPLOYERS' <br /> Y/N AVKCMN2767402019 02/01/2019 02/01/2020 X STATUTE EERH <br /> AND EMPLOYERS'LIABILITY <br /> ANYPROPRIETOR/PARTNER/EXECUTIVEF-] N/A E.L.EACH ACCIDENT $ 1,000,000 <br /> OFFICER/MEMBER EXCLUDED? <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 11000,000 <br /> If yes,describe under 1,000,000 <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> B Inland Marine CPP0020756 18 02/01/2019 02/01/2020 Rented/Leased $ 150,000 <br /> Equipment <br /> A Property - Commercial CPP0020756 18 02/01/2019 02/01/2020 $ <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) <br /> Project Name: Elk River Ice Arena and Lion John Weicht Park Facilities <br /> Stored Materials: Condenser stored material in amount of $104,800 <br /> The following entity's are included as additional insured with a waiver of subrogation in their <br /> favor: <br /> City of Elk River <br /> 13065 Orono Parkway NW <br /> Elk River, MN 55330 <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> RJM Construction <br /> 830 Boone Ave North AUTHORIZED REPRESENTATIVE <br /> Golden Valley MN 55427 <br /> ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br /> Page 1 of 2 <br />