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<br />15 <br />198004v3 <br />CERTIFICATE OF INSURANCE <br /> <br />LIABILITY & WORKERS' COMPENSATION <br /> <br /> <br />This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate <br />does not amend, extend or alter the coverage afforded by the policies listed below. <br /> <br /> <br />PROJECT: ___________________________________________ <br /> <br />CERTIFICATE HOLDER & ADDITIONAL INSURED: City of Arden Hills <br />ADDRESS: 1245 West Highway 96 <br /> Arden Hills, Minnesota 55112 <br /> <br />ARCH/ENGR:__________________________________________ <br /> <br />INSURED:_____________________________________________ <br />ADDRESS:___________________________________ <br /> <br /> <br />___________________________________ <br /> <br />AGENT: _______________________________________________ <br />ADDRESS:___________________________________ <br /> <br /> <br />___________________________________ <br /> <br />WORKERS' COMPENSATION COVERAGE <br /> <br />POLICY #_________________________ EFFECTIVE DATE_____/_____/_____ EXPIRATION <br />DATE_____/_____/_____ <br /> <br />INSURANCE COMPANY:________________________________________ <br /> <br />COVERAGE-Workers' Compensation, Statutory. Employers' Liability Limit <br /> $_____________Each Accident $______________Disease Policy Limit $______________ Disease Employee <br />Limit <br /> ($500,000 Policy limit applies to both accident and disease) <br /> <br /> <br />GENERAL LIABILITY <br /> <br />POLICY #_________________________EFFECTIVE DATE_____/_____/_____ EXPIRATION <br />DATE_____/_____/_____ <br /> <br />INSURANCE COMPANY:________________________________________________ <br /> ( )Claims Made ( )Occurrence ( )Owner's & Contractors Protective ( ) Other <br /> <br />LIMITS: <br /> General Aggregate Limit (Other Than Products-Completed Operations) $ ______________________ <br /> Products-Completed Operations Aggregate Limit $ ______________________ <br /> Personal & Advertising Injury Limit $ ______________________ <br /> Each Occurrence $ ______________________