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<br />ti>rac <br /> <br />Minnesota Workers' Compensation Assigned Risk Plan <br />Standard Workers' Compensation and Employers' Liability Policy <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 />CERTIFICATE OF INSURANCE <br /> <br />BerI<Iey R.k Administrators Compaoy, LLC <br /> <br />1. The Insured: <br />GNAW JNC <br />dba: Centerville Liquors <br />7093 20th Ave <br />Centerville, MN 55038 <br /> <br />Policy Number: WC-22-04-159728-00 <br />Association File Number: 3201395 <br /> <br />Tax 10#: F 830385468 <br />UIC #: 6870755000 <br />Policy Period: From: 1/6/2005 <br />To: 1/6/2006 <br /> <br />Date of Mailing: 11/9/2005 <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 /> <br />Employers' Liability <br /> <br />Bodily Injury by Accident $100,000 each accident. <br />Bodily Injury by Disease $500,000 policy limit. <br />Bodily Injury by Disease $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 /> <br />OFFICERS NOT COVERED. <br /> <br />/' <br /> <br />Certificate Holder's Name and Address: <br />City of Centerville <br />1880 Main Street <br />Centerville, MN 55038 <br /> <br />",J <br />,.,.,) <br />-1 ' <br /> <br />t,. <br />...~ <br />, ,\ <br />~., <br /> <br />. <br /> <br />Agency Name and Address <br /> <br />Ross Nesbit Agencies Jnc <br />Paulet Slater Agency <br />2610 University Ave W <br />St Paul, MN 55114 <br /> <br />~ <br /> <br />~ . n..' .p....nt..ti~.. <br /> <br />~11 <br />