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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 />AGENT: <br />ADDRESS: <br />WORKERS' COMPENSATION COVERAGE <br />POLICY # EFFECTIVE DATE <br />INSURANCE COMPANY: <br />COVERAGE -Workers' Compensation, Statutory. Employers' Liability Limit <br />$ Each Accident $ Disease Policy Limit $ <br />($500,000 Policy limit applies to both accident and disease) <br />GENERAL LIABILITY <br />EXPIRATION DATE <br />Disease Employee Limit <br />POLICY # EFFECTIVE DATE / / EXPIRATION DATE <br />INSURANCE COMPANY: <br />( )Claims Made ( )Occurrence ( )Owner's & Contractors Protective <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 />188905v1 23 <br />( ) Other <br />