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152229v01 <br />SMM:06/07/2010 <br />19 <br />CERTIFICATE OF INSURANCE <br />LIABILITY & WORKERS' COMPENSATION <br />This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This <br />certificate does not amend, extend or alter the coverage afforded by the policies listed below. <br />PROJECT:___________________________________________ <br />CERTIFICATE HOLDER & ADDITIONAL INSURED: City of Orono <br />ADDRESS: <br />ARCH/ENGR:__________________________________________ <br />INSURED:______________________________________ ADDRESS:___________________________________ <br /> ___________________________________ <br />AGENT:________________________________________ ADDRESS:___________________________________ <br /> ___________________________________ <br />WORKERS' COMPENSATION COVERAGE <br />POLICY #______________________ EFFECTIVE DATE____/____/____ EXPIRATION DATE____/____/____ <br />INSURANCE COMPANY:________________________________________ <br />COVERAGE-Workers' Compensation, Statutory. Employers' Liability Limit <br />$__________Each Accident $___________Disease Policy Limit $___________ Disease Employee Limit <br />($500,000 Policy limit applies to both accident and disease) <br />GENERAL LIABILITY <br />POLICY #______________________EFFECTIVE DATE____/____/____ EXPIRATION DATE____/____/____ <br />INSURANCE COMPANY:________________________________________________ <br /> ( )Claims Made ( )Occurrence ( )Owner's & Contractors Protective ( ) Other <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 />230