HomeMy WebLinkAboutBurschville Construction Company - 5/1-5/1/08
ACORD.. CERTIFICAT~ OF LIABILITY INSURANCE OP ID 1~ DATE (llM/DDIYYYY)
BtJRSCHV 04/26/07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
RJF Agencies, Inc. Plymouth HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
6000 Nathan Lane N., Suite 400 ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
Minneapolis MN 55442
Phone: 763-746-8000 INSURERS AFFORDING COVERAGE NAlC.
INSURED INSURER A: Western National Insurance 15377
Burschville Construction CO INSURER B: Travelers Ins. Co.
i&K s8en~l INSURER c:
ax 7 3-~ 7-4266
PO Box 6 INSURER 0:
Hanover MN 55341
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT. TERM OR CONDmON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDmONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR INSRt TYPE OF INSURANCE POUCY NUMBER ~lllM1lfDiWf DATE'IMMID~ LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000.000
- ~=~?~=nce)
A X X COMMERCIAL GENERAL LIABILITY CP300007926 05/01/07 05/01/08 $ 100.000
I CLAIMS MADE [jJ OCCUR MED EXP (Any one person) $ 5.000
~ Blkt Addl Insd PERSONAL & ADV INJURY $ 1.000,000
X contractual liab GENERAL AGGREGATE $2,000,000
-
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000
I POLICY Iil ~~8;: n LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
-
A X ANY AUTO CA300008438 05/01/07 05/01/08 (Ea accident)
-
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
- I tECEIVEC
HIRED AUTOS BODILY INJURY
- $
NON-oWNED AUTOS (Per accident)
- , PR 2 7 2007 ..
- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
=i ANY AUTO CE nERVILLE, iIlN OTHER THAN EAACC $
- AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $5,000,000
A ~ OCCUR D CLAIMS MADE CU300003110 05/01/07 05/01/08 AGGREGATE $5,000.000
$
~ DEDUCTIBLE $
X RETENTION $10.000 $
WORKERS COMPENSATION AND X [TORY LIMITS I I U ~~-
A EMPLOYERS' LIABILITY WC300003007 05/01/07 05/01/08 E.L. EACH ACCIDENT $100,000
ANY PROPRIETORIPARTNERlEXECUTIVE
OFFICER/MEMSER EXCLUDED? E.L DISEASE - EA EMPLOYEE $100,000
If ~e8. describe under E.L. DISEASE - POLICY LIMIT $ 500.000
S ECIAL PROVISIONS below
OTHER
B Lease/Rented QT660411X8343 05/01/06 05/01/07 Leased 350,000
Equipment Deduct 1,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Re: Baokage Road & 21st Ave Utility & Street Improvements project in
Centerville, Minnesota
Ci ty of Centerville and Bonestro, Rosene, ADderlik & Associates,
Inc. (engineer) areaadi fional "insured per-attached forms CG 2033 (07-04)
and CG 2037 07-04.
CERTIFICATE HOLDER
CANCELLATION
CITYOCE SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 80 SHALL
City ofCenterville IMPOSE NO OBUGATlON OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
1880 Main Street
Centerville MN 55038 REPRESENTATIVES.
AUTM9~RE!~2A .' -
~- 1'i
ACORD 25 (2001108)
@)ACORD CORPORATION 1988
.
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001108)