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06-11-18-R
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06-11-18-R
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<br />16 <br />198004v3 <br />COVERAGE PROVIDED <br /> <br /> Operations of Contractor: Yes_____ No_____ Government Immunity is Waived <br />Yes_____No_____ <br /> Operations of Sub-Contractor (Contingent): Yes_____ No_____ Property Damage Liability Includes <br /> Does Personal Injury Include Damage Due to Blasting <br /> Yes_____No_____ <br /> Claims Related to Employment: Yes_____ No_____ Damage Due to Collapse <br /> Yes_____No_____ <br /> Completed Operations/Products: Yes_____ No_____ Damage To Underground Facilities <br /> Yes_____No_____ <br /> Contractual Liability (Broad Form): Yes_____ No_____ Broad Form Property Damage <br /> Yes_____No_____ <br />EXCEPTIONS: <br /> <br />AUTOMOBILE LIABILITY <br /> <br />POLICY #__________________________ EFFECTIVE DATE: ____/____/____ EXPIRATION DATE: <br />____/____/____ <br /> <br />INSURANCE COMPANY: _______________________________________ <br /> ( )Any Auto ( )All Owned Autos ( )Scheduled Autos <br /> ( )Hired Autos ( )Non-Owned Autos <br /> <br />LIMITS: <br /> Bodily Injury $____________Each Person / $___________Each Occurrence OR Combined Single Limit <br />$______________ <br /> Property Damage $______________Each Occurrence <br /> <br />UMBRELLA EXCESS LIABILITY <br /> <br />POLICY #_______________________ EFFECTIVE DATE:_____/_____/_____ EXPIRATION <br />DATE:_____/_____/_____ <br /> <br />INSURANCE COMPANY_________________________________________ <br /> <br />LIMITS: Single Limit Bodily Injury and Property Damage <br /> <br /> $_______________Each Occurrence $__________________Aggregate <br /> <br />COVERAGE PROVIDED: <br /> Applies in excess of the coverages listed above for Employers' Liability, General Liability, and Automobile Liability: <br /> <br /> Yes_____ No_____ <br /> <br /> Are any deductibles applicable to bodily injury or property damage on any of the above coverages? <br /> <br /> Yes_____No_____ If So, List Amount $________________ <br /> <br />AGENT CARRIES ERRORS AND OMISSIONS INSURANCE: Yes_____No_____ <br /> <br />Should any of the above described policies be cancelled before the expiration date thereof, the issuing company will mail <br />30 days notice to the parties to whom this certificate is issued. <br /> <br />Dated at: ________________________ On: _______________________ By: ______________________________ <br /> <br />MN License #________ Authorized Insurance Representative
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