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EXHIBIT "C"TO SUBDIVISION AGREEMENT <br /> CERTIFICATE OF INSURANCE <br /> PROJECT: <br /> CERTIFICATE HOLDER:City of CENTERVILLE <br /> 1880 Main Street <br /> CENTERVILLE,Minnesota 55038 <br /> INSURED: <br /> ADDITIONAL INSURED: City of CENTERVILLE <br /> AGENT: <br /> WORKERS' COMPENSATION: <br /> Policy No. <br /> Effective Date: Expiration Date: _ <br /> Insurance Company: <br /> COVERAGE-Workers' Compensation, Statutory. <br /> GENERAL LIABILITY: <br /> Policy No. <br /> Effective Date: Expiration Date: <br /> Insurance Company: <br /> ()Claims Made ()Occurrence <br /> LIMITS: [Minimum] <br /> Bodily Injury and Death: <br /> $500,000 for one person $1,000,000 for each occurrence <br /> Property Damage: <br /> $200,000 for each occurrence <br /> -OR- <br /> Combination Single Limit Policy $1,000,000 or more <br /> COVERAGE PROVIDED: <br /> Operations of Contractor: YES <br /> Operations of Sub-Contractor(Contingent): YES <br /> Does Personal Injury Include Claims Related to Employment? YES <br /> Completed Operations/Products: YES <br /> Contractual Liability(Broad Form): YES <br /> Governmental Immunity is Waived: YES <br /> Property Damage Liability Includes: <br /> VKG--2017-11-03 Page 25 <br /> 40 <br />