04-19-21-WS - Laserfiche WebLink

Home Browse Search

187184v1 34 COVERAGE PROVIDED Operations of Contractor: Yes____ No____ Government Immunity is Waived Yes____ No____ Operations of Sub-Contractor (Contingent): Yes____ No____ Property Damage Liability Includes Does Personal Injury Include Damage Due to Blasting Yes____ No____ Claims Related to Employment: Yes____ No____ Damage Due to Collapse Yes____ No____ Completed Operations/Products: Yes____ No____ Damage To Underground Facilities Yes____ No____ Contractual Liability (Broad Form): Yes____ No____ Broad Form Property Damage Yes____ No____ EXCEPTIONS: AUTOMOBILE LIABILITY POLICY #________________________ EFFECTIVE DATE: ___/___/___ EXPIRATION DATE: ___/___/___ INSURANCE COMPANY: _______________________________________ ( )Any Auto ( )All Owned Autos ( )Scheduled Autos ( )Hired Autos ( )Non-Owned Autos LIMITS: Bodily Injury $_________ Each Person / $________ Each Occurrence OR Combined Single Limit $__________ Property Damage $_____________ Each Occurrence UMBRELLA EXCESS LIABILITY POLICY #_____________________ EFFECTIVE DATE:____/____/____ EXPIRATION DATE:____/____/____ INSURANCE COMPANY_________________________________________ LIMITS: Single Limit Bodily Injury and Property Damage $_______________Each Occurrence $__________________Aggregate COVERAGE PROVIDED: Applies in excess of the coverages listed above for Employers' Liability, General Liability, and Automobile Liability: Yes_____ No_____ Are any deductibles applicable to bodily injury or property damage on any of the above coverages? Yes_____ No_____ If So, List Amount $________________ AGENT CARRIES ERRORS AND OMISSIONS INSURANCE: Yes_____No_____ Should any of the above described policies be cancelled before the expiration date thereof, the issuing company will mail 30 days notice to the parties to whom this certificate is issued. Dated at: ________________________ On: _______________________ By: ____________________________ MN License #________ Authorized Insurance Representative