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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 <br />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 <br />Liability: <br />Yes No <br />Are any deductibles applicable to bodily injury or property damage on any of the above coverages? <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 <br />company will 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 />235929v3