|
WELLCOM-01 DERSHI
<br />`� CERTIFICATE aF LIABILITY INSURANCE D TE( !7 fY l
<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 pollcy(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 endorsements .
<br />PRODUCER
<br />Heartman insurance
<br />1606 E. Main Street
<br />Albert Lea, MN 56007
<br />C TAC7
<br />PAHrCO, No E,, : (507) 373-6446 FAX No :(507) 373-8424
<br />E-MAI info heartman.Corn
<br />INSU R S AFFORDING COVERAGE
<br />NAiC N
<br />INSURER :Travelers
<br />19038
<br />INSURED
<br />The Wells Companies, Inc and its subsidiaries
<br />PO Box 656
<br />Albany, MN 56307-0656
<br />INSURER a :Charter Oak Fire Insurance Company
<br />25615
<br />INSURER C:Cincinnati Insurance Company
<br />10677
<br />INSURER D :
<br />INSURER E :
<br />INSURER F -
<br />17PVIQlnkt IUI IMRFR•
<br />I,VYCRMUGA v�r",,v 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
<br />TYPE OF INSURANCE
<br />ADDL
<br />SUBRwin Awn.
<br />POLICY NUMBER
<br />POLICY EFF
<br />POLICY BxP
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />5 1,000,000
<br />CLAIMS -MADE F_X] OCCUR
<br />X
<br />X
<br />630-9F284958
<br />411/2019
<br />4/112020
<br />DAMAGETORENTED ee
<br />100,000
<br />MED EXP (Any oneperson)
<br />5,000
<br />PERSONAL&ADV INJURY
<br />1,000,600
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />POLICY ® jFe7 n LOG
<br />GENERAL AGGREGATE
<br />S 2,000,000
<br />PRODUCTS -CCMPIOPAGG
<br />2,0001000
<br />A
<br />OTHER:
<br />AUTOMOBILE LIABILITY
<br />COMBINED SINGLE LIMIT
<br />a
<br />1,000,000
<br />S
<br />BODILY INJURY Per a son
<br />X ANY AUTO
<br />X
<br />X
<br />810-80563318
<br />411/2019
<br />41112020
<br />BODILYINJURYPeraccldenl
<br />AUQSONLY AUTOSLILED
<br />IRECH DULI�p
<br />X AUTOS ONLY rxA11T05 ONLY
<br />Pe0accltlenl AMAGE
<br />A
<br />X
<br />UMBRELLA LIAR
<br />EXCESSLIAs
<br />X
<br />OCCUR
<br />CLAIMS -MADE
<br />CUP-1J604373
<br />41112019
<br />411/2020
<br />EACH OCCURRENCE
<br />$ ,000,000
<br />AGGREGATE
<br />6 ,OOD,000
<br />DED I X I RETENTIONS 10,000
<br />B
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIErORIPARTNERIEXECLrTIVE
<br />OFFICERIMEMBI;IEXCLUDED? a
<br />(Mandatory in hIH]
<br />Ives, describe under
<br />SCRIPTIONOFOPERATIONSbelow
<br />Leased Rented Equip
<br />N!A
<br />UB3K310176
<br />660.8A136732
<br />411/2019
<br />411/2019
<br />41112020
<br />4/112020
<br />PER OTH-
<br />�( A LIFT ER
<br />E.L. EACH ACCIDENT
<br />600,000
<br />E.L. DISEASE - EA EMPLOYE
<br />500,000
<br />E.L. DISEASE -POLICY LIMIT
<br />Leased Rented Equip
<br />600,000
<br />S
<br />1,500,000
<br />C
<br />Excess Umbrella
<br />EXS 0379319
<br />41112019
<br />41112020
<br />Excess Umbrella
<br />6,000,000
<br />DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule maybe attached IF more • ce in required),
<br />WC Job# 7104. Project- Elk River New Cammunity Center. RJM Construction, LL6, City of Elk River, 292 Design Group and all other parties per written
<br />contract are named as additional Insured on a primary & non-contributory basis with respects to the General Liability. Waiver of subrogation applies to the
<br />General Liability. Automatic additional insured & Waiver of subrogation an the Auto Liability coverage. Umbrella follows form. Should the insurance company
<br />cancel the above insurance for any other reason than non-payment of premium 30 day notice will be mailed. The Work Comp coverage is for the following
<br />states Iowa, South Dakota, Colorado, and Wisconsin. Minnesota is self- insured. Stored materials in the amount of $401.609.73.
<br />t+AKIPCI I ATIAhF
<br />ucrcr rri%om r nv,
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />RJM Construction
<br />THE EXPIRATION BATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />830 Boone Ave N
<br />Golden Valley, MN 55427
<br />AUTHORIZED REPRESENTATIVE
<br />ACORD 25 (2016/03) Oa 198E-2015 AGpRU L;[ kpCjKA i iON. Aii ngnis reserves.
<br />The ACORD name and logo are registered marks of ACORD
<br />
|