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HomeMy WebLinkAboutWright Tree Service Inc. r , t CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD - BOX 2007 OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439 -4439 + , r CITY OF OAK PARK HEIGHTS 2012 TREE WORKER'S LICENSE APPLICATION Date: (t -as- L( Firm or Business Name: W rl'g Try S r /tet t AC Type of tree work to be performed: UktilA4 a LICENSE REQUIREMENTS ♦ Certificate of Insurance, minimum coverage, $1,000,000 combined single limit coverage, covering all operations of the applicant. THE CITY OF OAK PARK HEIGHTS MUST BE NAMED AS AN ADDITIONAL INSURED on this policy. ♦ Agreement to hold THE CITY OF OAK PARK HEIGHTS harmless for ALL claims of damage liability that may come against the license /permit holder. ♦ Proof of WORKERS COMPENSATION INSURANCE. ♦ State and Federal Tax Identification numbers pursuant to MN STATE STATUTE 270.72. ♦ The CONTRACTOR further agrees to adhere to all OSHA STANDARDS, UNIFORM TRAFFIC CODES and any CITY CODES AND STANDARDS that may apply to this license. Licenses held in nearby cities: 63,301 Gel,(c_2_Ve t te_ Has your company ever had a license revoked in any other city? (YES) G If yes, where? � , �, r LICENSE FEE: $30.00 (IS -31 -- ( - ✓�.1 V Kik (ne. Name di Business or Company COMPLETION OF THE WORKERS ! ?t (D-4-k 54 COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED f, 1 De ,C Nn� BEFORE A LICENSE CAN BE ISSUED. W. 2S I Y �( ll « SCTr kitS THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF ( ��S) -V11. —4 l THE CALENDAR YEAR WITHIN Phone Number, WHICH APPLIED FOR OR UPON te_fdkt j r o wn g Le- kin EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS' COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: ' Date: ((' ( it ACA - 0000 LICENSE APPLICANT: Pursuant to Minnesota Statute 270.072 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of this information: 1. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest; 2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement the Department of Revenue may supply this information to the Internal Revenue Service. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. Please provide the following information and return along with your application to the agency issuing the license. Do not return to the Department of Revenue. Licensing Authority: The City of Oak Park Heights License Renewal Date: Annually (January 15t through December 31 Personal Information: (Complete only if applicable) Applicant's Name: Applicant's Address: City State Zip Code Social Security No.: Business Information: (Complete only if applicable) Business Name: WY� - Tree CQJII\f et (. v\C Business Address: e76)( (1 Dec (V1b tines sa 30(.0 City State Zip Code Minnesota Tax Identification No.: IS t (0 II II Federal Tax Identification No.: `yet -086 046.1 If a Minnesota Tax Identification number is not required, please explain: — Signature Title Date 4• ,f CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD - Box 2007 OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439 -4439 PROOF OF WORKERS' COMPENSATION INSURANCE COVERAGE Minnesota Statue, Section 176.182, requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of Section 176.181, subdivision 2. The information required is: the name of the insurance company, the policy number, and dates of coverage or the permit to self- insure. This information will be collected by the licensing agency and placed within their company file. It shall be furnished, upon request, to the Department of Labor and Industry to check for compliance with Minnesota Statue, Section 176.182, subdivision 2. Law requires this information; licenses and permits to operate a business may not be issue or renewed if it is not provided and /or is falsely reported. Furthermore, failure to provide or falsely reporting this information may result in a $1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry to the Special Compensation Fund. Provide the information specified above, in the spaces provided, or certify the precise reason your business is excluded from compliance with the insurance coverage requirement for workers' compensation. Insurance Company (not the Insurance Agent): $ , a c• Policy Number or Self- Insurance Permit Number: Dates of Coverage: OR I am not required to have Workers' Compensation Insurance because: (check one) I have no employees covered by law Other (specify) •. I have read and understand my rights an • _�: aoh u, •usiness licenses, permits and Workers' Compensation coverage ans''� y 6)IAN>y"s `a; re below that to the best of my knowledge, the information provid • • _- - . • 1.1 _ - J �_I!l. l ft)r ¶rre ✓C.Y Y Lc (w Signature • Pres me (i ti5 Date: � c i �Q 11 I► )O (n es-, (k 7 OSOCio Business Address f Telephone Number: 61 s ! j s . CITY OFOAK PARK HEIGHTS 14168 OAK PARK BOULEVARD- BOX 2007 OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439 -4439 INDEMNIFICATION AGREEMENT To: The City of Oak Park Heights 14168 Oak Park Boulevard P.O. Box 2007 Oak Park Heights, MN 55082 NOTE: The following must be signed by an Officer of the Corporation or by the Owner and notarized. In consideration for the granting of this license, the license applicant agrees to hold the City harmless from all damages and claims of damage which may arise by reason of any negligence on the part of the Contractor or the Contractor's agents or employees engaged in the performance of this Contract /Permit, and will indemnify the City for the amount of all claims, liens, expenses and claims for liens of work, tool, machinery, materials or insurance premiums and for the amount of all loss by reason of the failure of the Contractor to fully perform its obligation under this Contract /Permit, including but not limited to attorney fees and costs incurred relative to such claims and losses. ( t By: !al lb' Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this day of WON , 2.461jl �_ V` — — , Notary Public. 'C- County. My commission expires HN * ,Q ; * ConxnleNon Number 1 4396 awr CO^ion EN'S MARCH 20 2013 S:Shared /Forms /Arborist /Tree Worker's License Application • A DATE (MM/OD/YYYI) °� CERTIFICATE OF LIABILITY INSURANCE 09/19/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 1- 612 - 333 -3323 CONTACT Deanna Brown NAME: Hays Companies PHONE 612 333 -3323 FAX 612 - 373 - 7270 (A/C. No. Ext): (AIC, No): 80 South 8th Street EMAIL ADDRESS: Suite 700 PRODUCER Minneapolis, MN 55402 CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA: CONTINENTAL CAS CO 20443 Wright Tree Service, Inc. INSURERB: AMERICAN CAS CO OF READING PA 20427 PO Box 1718 INSURERC: TRANSPORTATION INS CO 20494 Des Moines, IA 50306 INSURER D: INSURER E : INSURERF: WRIGH - COVERAGES CERTIFICATE NUMBER: 23112087 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM /DD/YYYY) (MMIDDYYY) A GENERAL LIABILITY GL2074976960 10 /01 /1 10/01/12 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 500, 000 PREMISES (Ea occurrence) $ CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 15,000 X BI /PD Ded. $350,000 PERSONAL &ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 1, 000, 000 POLICY X PF LOC $ A AUTOMOBILE LIABILITY BUA2074976974 10 /01 /1 10/01/12 COMBINED SINGLE LIMI $ 2,000,000 (Ea accident) X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON -OWNED AUTOS _ $ X BI /PD Ded. $350,000 $ A X UMBRELLA LIAB X OCCUR L4017615770 10 /01 /1 10/01/12 EACH OCCURRENCE $ 20,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $ 20, 000, 000 DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION WC274976926 10/01/1 10/01/12 X TORYLIMTS HR AND EMPLOYERS' LIABILITY B ANY PROPRIETOR/PARTNER /EXECUTIVE Y/N 10 / O 1 / 12 WC274976912 (CA) 10 /01 /1 E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 C Workers Compensation WC274976943 10 /01 /1 10/01/12 Em ployersLiability 1mm /1mm /lmm EL Disease -Ea EE 1,000,000 EL Disease Pol Lmt 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) City of Oak Park Heights is an Additional Insured under the General Liability policy as required by contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Blvd Box 2007 AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 55082 USA treed © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 23112087 szt ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) 09/28/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 1 - 612 - 333 - 3323 CONTACT Deanna Brown NAME: Hays Companies PHONE FAX 612 - 373 - 7270 (NC. , No, Extl: 612 (AIC, No): E 80 South 8th Street ADDRESS: Suite 700 - - - - - - -- PRODUCER Minneapolis, MN 55402 RECEIVED ' CUSTOMER ID It: INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: ZURICH AMER INS CO 16535 Wright Tree Service, Inc. INSURER B: STARR IND & LIAB CO 38318 PO Box 1718 OCT — 1 roi - ! i j INSURERC: AMERICAN ZURICH INS CO 40142 INSURER D Des Moines, IA 50306 INSURER E : City of Oak Park Heights INSURER F : COVERAGES CERTIEIC&TFMMMRER: 2FM5334 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE SEED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL yy D POLICY NUMBER IMM/DDYM'YY) IMMIDD/YYYY) LIMITS A GENERAL LIABILITY GL0591264900 10/01/12 10/01/13 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 500,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 15, 000 X BI /PD Ded. $350,000 PERSONAL &ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 POLICY IFS7 X LOC A AUTOMOBILE LIABILITY BAP 591264800 10/01/12 10/01/13 COMBINED SINGLE LIMIT $ 2,000,000 (Ea accident) X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON -OWNED AUTOS $ X BI /PD Ded. $350,000 $ B X UMBRELLA LIAB X OCCUR SISCCCL01930812 10/01/12 10/01/13 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $ 5,000,000 DEDUCTIBLE $ _ RETENTION $ C WORKERS COMPENSATION WC591265000 10/01/12 10/01/13 X WCSTATU- TH O- AND EMPLOYERS' LIABILITY TORY LIMITS ER Y ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 _ - OFF16ER/MEMBER EXCLUDED? s1 __ - - __. ______. _.. ___. __— _ -__. _. _. ________ _. _ (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1, 000, 000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Workers Compensation - Retro WC591265300 10/01/12 10/01/13 EmployersLiability lmm /lmm /lmm EL Disease -Ea EE 1,000,000 EL Disease Pol Lmt 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) City of Oak Park Heights is an Additional Insured under the General Liability policy as required by contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Blvd Box 2007 AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 55082 USA ericj © 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 29365834