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<br />Vi/~.I.VV~ ~~;~O rAA ~l~iUbJU~~ <br /> <br />tT>rac <br /> <br />Biltt!9tRlel.A<l'mlrthUra!~~.lLC <br /> <br />tihKKLb~ HI~K ADMIN. <br /> <br />141 0.02/002 <br />I <br />~ <br />I <br /> <br />Minnesota Workers' Compensation Assigned Risk Plan <br />Standard Workers' Compensation and Employers' Liability Policy <br />ContrClct Administrator <br />Berkley Risk Administrators Company, LLC <br />P.O. Box 59143 Minneapolis, Minnesota 5S459-<J143 <br />Phone (612) 766-3000 NCCf CClrrier Code 21466 I <br />CERTIFICATE 01' INSURANCE t <br />Polley Number: WC-22-04-15PB55-00 <br />ASsociation File Number: 3166600 I <br /> <br />. <br /> <br />1. The Insured: <br />Center Mart L.LC <br />1801 Main 5t <br />Centervllle, MN 55038 <br /> <br />Tax 10#: F 201141552 <br />ule #: UNKNOWN <br />Policy Period; From; 7/212004 <br />To: 7/212005 <br /> <br />Date of Mailing: 7/12/2004 <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 dooument <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 conclJtions of such Policy. <br /> <br /> <br />Part One <br />Worke",' Compensation <br /> <br />Part Two <br />Employers' Liability <br /> <br />Statutory <br /> <br />Bodily Injury by Accident <br />Bodily Injury by Disease <br />Bodily Injury by Disease <br /> <br />$100,000 each accident. <br />$500,000 policy limn. <br />$100,000 each employee. <br /> <br />Should the above Policy be canceled before the expiration d..te 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 />Certificate Holders Name and Address; <br />City of Centerville <br />1880 Main Street <br />Centervi/le, MN 55038 <br /> <br />OFFICERS NOT COVERED. <br /> <br />AClenCy Name and Address <br /> <br />Date Issued: 7/1211.004 <br /> <br />All County Agency <br />255 SE Hwy 97 Suite 38 <br />Forest Lake, MN 1)5025 <br /> <br />~~~,. <br /> <br />BA3140 <br />