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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, MN 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 /> O Claims Made O 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 /> Version for Council Packet - 10/19/2018 Page 27 <br /> 93 <br />