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<br />USE WITH DESIGN AGREEMENTS
<br />
<br />ACORD
<br />
<br />
<br />Issue Date:
<br />April 3, 2007
<br />
<br />PRODUCER:
<br />
<br />SAMPLE
<br />
<br />Sample Professional Insurance Agency
<br />1200 Main Street
<br />Minneapolis, MN 55402
<br />FAX: (612) 555-1000 Phone: (612) 555-1100
<br />Contact: Bill Johnson
<br />
<br />INSURED:
<br />
<br />Sample Architects & Engineers Group,
<br />
<br />1500 Industrial Boulevard
<br />
<br />Minneapolis, MN 55402
<br />
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
<br />
<br />ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.
<br />THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
<br />COVERAGE AFFORDED BY THE POLICIES BELOW
<br />
<br />COMPANIES AFFORDING COVERAGE
<br />
<br />COMPANY A Dependable Casualty Insurance Company
<br />COMPANY B Dependable Indemnity Company
<br />COMPANYC Global Indemnity Company
<br />COMPANY D Professional Liability Underwriters CO
<br />COMPANY E
<br />
<br />
<br />
<br />
<br />
<br />REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY
<br />AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN
<br />CLAIMS.
<br />
<br />CO
<br />
<br />L TR TYPE OF INSURANCE
<br />
<br />DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
<br />Certificate applicable to all projects for which Insured is performing services as a Design Consultant, Architect or Engineer for Ryan Companies US, Inc. or
<br />its subsidiaries. Ryan Companies US, Inc. ("Ryan") and the Owner of any Project for whom Ryan is working shall be named as additional insureds on the
<br />above Commercial General Liability and Umbrella/Excess Liability policies. Professional Liability policy shall have a "retroactive date" not later than the date
<br />()~""Y~ic:~,.,~~'Yi~~,<:i~~,~,~~~,,P~,!9r!1:l,e~ .
<br />CERIIEIC.6.TE'Ii/O[OER
<br />Ryan Companies US, Inc,
<br />50 South Tenth Street
<br />Suite 300
<br />Minneapolis, MN 55403
<br />Alln: Sue Hayes
<br />
<br />POLICY NUMBER
<br />
<br />A
<br />
<br />GENERAL LIABILITY
<br />[8]Commercial General Liability
<br />o Claims Made IRI Occur.
<br />DOwner's & Contractor's Prot
<br />[8] General Agg - Per Project
<br />o
<br />AUTOMOBILE LIABILITY
<br />I:&l Any Auto
<br />1RI All Owned Autos
<br />1RI Scheduled Autos
<br />1RI Hired Autos
<br />1RI Non-Owned Autos
<br />
<br />D Gara e Liabili
<br />EXCESS LIABILITY
<br />Umbrella Form
<br />o Other than Umbrella Form
<br />WORKER'S COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />
<br />WC1234567
<br />
<br />GL 1234567/
<br />
<br />B
<br />
<br />AL1234567
<br />
<br />B
<br />
<br />UMX1234567
<br />
<br />c
<br />
<br />o
<br />
<br />OTHER
<br />Professional Liability
<br />Retroactive Date:
<br />
<br />PL 1234567
<br />
<br />Fax #: (612) 492-3310
<br />
<br />THE INSURANCE
<br />BY PAID
<br />
<br />Policy
<br />Effective Date
<br />
<br />Policy
<br />Ex iration Date
<br />
<br />LIMITS
<br />
<br />4/0 1/00
<br />
<br />GENERAL AGGREGATE $
<br />PRODUCTS-COMP OPS AGG. $
<br />PERSONAL&ADV.INJURY $
<br />EACH OCCURRENCE $
<br />FIRE DAMAGE (ANY ONE FIRE) $
<br />MEQ, EXPENSE (ANY ONE PERSON) $
<br />COMBINED SINGLE LIMIT $
<br />
<br />1,000,000
<br />1,000,000
<br />1,000,000
<br />1,000,000
<br />50,000
<br />5,000
<br />1,000,000
<br />
<br />4/01/01
<br />
<br />4/0 1 /00
<br />
<br />4/01/01
<br />
<br />BODILY INJURY (PER PERSON) $
<br />
<br />4/01/00
<br />
<br />BODILY INJURY (PER ACCIDENT) $
<br />PROPERTY DAMAGE
<br />Comprehensive Deductible
<br />EACH OCCURRENCE
<br />AGGREGATE
<br />
<br />4/01/01
<br />
<br />
<br />4/01/00
<br />
<br />4/01/01
<br />
<br />100,000
<br />500,000
<br />100,000
<br />
<br />EL DISEASE - POLICY liMIT
<br />EL DISEASE - EACH EMPLOYEE
<br />
<br />4/01/00
<br />
<br />4/01/01
<br />
<br />$2,000,000 Each Clalm/$2,000,OOO Aggregate
<br />(If architectural or structural services) 0
<br />$1,000,000 Each Claim/$1,OOO,OOO Aggregate
<br />If other desi n/ rofessional services 0
<br />
<br />
<br />
<br />
<br />ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
<br />THEREOF, THE ISSUING COMPANY WILL E~II)[A'.'OR T9 MAIL ~DAYS WRITTEN NOTJCE TO THE
<br />CERTIFICATE HOLDER NAMED TO THE LEFT. BIJT r'\ILLJRE T9 fAAIL 8IJCIl HOTICE 81 tALL IMr98E tJO
<br />OBbJC'!.TIOtJ OR bJ'\BILlTY or ^rJ" 1<ltJD urgrJ TI IE CDrlP#J\f, m: ^CEtlTS OR RErn.CSCtJT\1WCS.
<br />
<br />AUTHORIZED REPRESENTATIVE
<br />Signature
<br />
<br />EX_0077MDOC
<br />
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