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<br />tirac <br /> <br />Bmfdsy RIsk AdmInIstmfDr8 ClIrnpany. LLC <br /> <br />Minnesota Workers' Compensation Assigned Risk Plan <br />Standard Workers' Compensation and Employers' Uability Policy <br /> <br />Contract Administrator <br />Berkley Risk Administrators Company, LLC <br />P.O. Box 59143 Minneapolis, Minnesota 55459-0143 <br />Phone (612) 766-3000 . NCCI Carrier Code 21466 <br /> <br />CERTIFICATE OF INSURANCE <br /> <br />.ppT 1 6 ,UOJ <br /> <br />1. The Insured: <br />Sahawk Ine <br />dba: Sagers Liquor <br />7093 20th Ave S <br />Centervllle, MN 56038 <br /> <br />Policy Number: WC-22-o4-127014-01 <br />Association Rle Number: 3154623 <br /> <br />TaxlD#:F411907983 <br />UIC #: 3136744000 <br />Policy Period: From: 2/612003 <br />To: 2/612004 <br /> <br />The Certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. <br />This Certificate does not amend, extend or alter the coverage afforded by the Policy listed below. <br /> <br />This is to certify that the Policy of Insurance described herein has been issued to the Insured named above for <br />the policy period indicated. Notwithstanding any requirement, term or condition of any contract or other document <br />with respect to which this Certificate may be issued or may pertain, the insurance afforded by the Policy described <br />herein is subject to all the terms, exclusions and conditions of such Policy. <br /> <br /> <br />Part One <br />Workers' Compensation <br /> <br />Statutory <br /> <br />Part Two <br />Employers' Uability <br /> <br />Bodily Injury by Accident <br />Bodily Injury by Disease <br />Bodily Injury by Disease <br /> <br />$100,000 each accident. <br />$500,000 policy limit. <br />$100,000 each employee. <br /> <br />Should the above Policy be canceled before the expiration date thereof, the Company <br />will endeavor to mail 30 days written notice to the below named Certificate Holder, but <br />failure to mail such notice shall impose no obligation or liability of any kind upon the Company. <br />All Entitlesllnsureds: <br />Sahawk Ine <br /> <br />Certificate Holders Name and Address: <br />City of Centervllle <br />1880 Main Street <br />Centerville, MN 55038 <br /> <br />OFFICERS NOT COVERED. <br /> <br />Agency Name and Address <br /> <br />Date Issued: 10/1012003 <br /> <br />Paulet Slater Ine <br />2610 University Ave W Ste 200 <br />St Paul, MN 55114 <br /> <br />-/~~- <br /> <br />BA3140 <br /> <br />.. <br /> <br />. <br /> <br />