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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 />Property Damage Liability Includes: <br />Version 08/20/2021 for Council packet Page 26 <br />