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152229v01 <br />SMM:06/07/2010 <br />20 <br />COVERAGE PROVIDED <br />Operations of Contractor: Yes____ No____ Government Immunity is Waived Yes____No____ <br />Operations of Sub-Contractor (Contingent): Yes____ No____ Property Damage Liability Includes <br />Does Personal Injury Include Damage Due to Blasting Yes____No____ <br />Claims Related to Employment:Yes____ No____ Damage Due to Collapse Yes____No____ <br />Completed Operations/Products:Yes____ No____ Damage To Underground Facilities Yes____No____ <br />Contractual Liability (Broad Form):Yes____ No____ Broad Form Property Damage Yes____No____ <br />EXCEPTIONS: <br />AUTOMOBILE LIABILITY <br />POLICY #________________________ EFFECTIVE DATE: ___/___/___ EXPIRATION DATE: ___/___/___ <br />INSURANCE COMPANY: _______________________________________ <br />( )Any Auto ( )All Owned Autos ( )Scheduled Autos <br />( )Hired Autos ( )Non-Owned Autos <br />LIMITS: <br /> Bodily Injury $_________ Each Person / $________ Each Occurrence OR Combined Single Limit $__________ <br /> Property Damage $_____________ Each Occurrence <br />UMBRELLA EXCESS LIABILITY <br />POLICY #_____________________ EFFECTIVE DATE:____/____/____ EXPIRATION DATE:____/____/____ <br />INSURANCE COMPANY_________________________________________ <br />LIMITS: Single Limit Bodily Injury and Property Damage <br /> $_______________Each Occurrence $__________________Aggregate <br />COVERAGE PROVIDED: <br /> Applies in excess of the coverages listed above for Employers' Liability, General Liability, and Automobile Liability: <br /> <br /> Yes_____ No_____ <br /> Are any deductibles applicable to bodily injury or property damage on any of the above coverages? <br /> <br /> Yes_____No_____ If So, List Amount $________________ <br />AGENT CARRIES ERRORS AND OMISSIONS INSURANCE: Yes_____No_____ <br />Should any of the above described policies be cancelled before the expiration date thereof, the issuing company will <br />mail 30 days notice to the parties to whom this certificate is issued. <br />Dated at: ________________________ On: _______________________ By: ____________________________ <br />MN License #________ <br />Authorized Insurance Representative <br />231