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DRAFT <br />24 <br />232402v15 <br />CERTIFICATE OF INSURANCE <br /> <br />LIABILITY & WORKERS’ COMPENSATION <br /> <br /> <br />This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate <br />does not amend, extend or alter the coverage afforded by the policies listed below. <br /> <br /> <br />PROJECT: ___________________________________________ <br /> <br /> <br />CERTIFICATE HOLDER & ADDITIONAL INSURED: City of Orono <br />ADDRESS: <br /> <br />ARCH/ENGR:__________________________________________ <br /> <br />INSURED:______________________________________ ADDRESS:___________________________________ <br /> ___________________________________ <br /> <br />AGENT:________________________________________ ADDRESS:___________________________________ <br /> ___________________________________ <br /> <br />WORKERS’ COMPENSATION COVERAGE <br /> <br />POLICY #______________________ EFFECTIVE DATE____/____/____ EXPIRATION DATE____/____/____ <br /> <br />INSURANCE COMPANY:________________________________________ <br /> <br />COVERAGE-Workers’ Compensation, Statutory. Employer’ Liability Limit <br /> $__________Each Accident $___________Disease Policy Limit $___________ Disease Employee Limit <br /> ($500,000 Policy limit applies to both accident and disease) <br /> <br /> <br />GENERAL LIABILITY <br /> <br />POLICY #______________________EFFECTIVE DATE____/____/____ EXPIRATION DATE____/____/____ <br /> <br />INSURANCE COMPANY:________________________________________________ <br /> ( )Claims Made ( )Occurrence ( )Owners & Contractors Protective ( ) Other <br /> <br />LIMITS: <br /> General Aggregate Limit (Other Than Products-Completed Operations) $ ______________________ <br /> Products-Completed Operations Aggregate Limit $ ______________________ <br /> Personal & Advertising Injury Limit $ ______________________ <br /> Each Occurrence $ ______________________ <br />172