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<br /> <br />Issue Date (MM/DDIYYYY) <br />10/18/2005 <br /> <br />Producer <br />All County Agency <br />255 SE Highway 97 Suite 3B <br />Forest Lake, MN 55025 <br /> <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO <br />RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, <br />EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br /> <br />COVERAGE PROVIDED BY <br /> <br />Insured <br />Center Mart LLC <br />1801 Main St <br />Centerville, MN 55038 <br /> <br />STATE FUND MUTUAL INSU.RANCE <br />3500 AMERICAN BLVD. WEST <br />SUITE 700 <br />BLOOMINGTON, MN 55431-4434 <br /> <br /> <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRA TlON <br />DATE (MMlDDIYYYY) DATE (MMIDDNYYY) <br /> <br />. __W08I<Ea'SCOMI'ENSATIQN__.__ _~_n24089.20L____ ._07l02/2005 ..___ U_", __ _07/0212006_.__ <br /> <br />LIMITS <br /> <br />AND <br />EMPLOYERS' LIABILITY <br /> <br />._ STATUTORY' LIMITS. <br />EACH ACCIDENT <br />POLICY LIMIT <br />DISEASE-EACH EMPLOYEE <br /> <br />100 000 <br />$500 000 <br />$100,000 <br /> <br /> <br /> <br />-,,,..~ -"~,< ~"' J'- .~""..... D <br />~"':." r;.......'. j;! " 'Ii'.' '1;i rrb' ~ <br />.!~.u l~l ~ ~ ~ .r.:, ~ . <br /> <br />OCT 1 9 Z004 <br /> <br />DESCRIPTION OF OPERATlONSlLOCATIONSJSPECIALITEMS <br /> <br />This Workers Compensation applies only to Minnesota employees working in Minnesota or while working temporarily out of the state of <br />Minnesota. <br /> <br /> <br />City of Centerville <br />Attn: Teresa Bender <br />1880 Main St <br />Centerville, MN 55038 <br /> <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL <br />30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. <br />BUT FAILURE TO MAIL SUCH NOTICE SHAlL IMPOSE NO OBLIGATION OR LIABILITY OF <br />ANY KIND UPON THE COMPANY, ITS NTS OR REPRESENTATIVES. <br />AUTHORIZED REPRESENTATlV <br /> <br /> <br />