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HomeMy WebLinkAboutWright Tree Service, Inc. CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD-BOX 2007 OAK PARK HEIGHTS,MINNESOTA 55082 (651)439-4439 CITY OF OAK PARK HEIGHTS 2014 TREE WORKER'S LICENSE APPLICATION Date: 11/22/13 Firm or Business Name: Wright Tree Service, Inc. Type of tree work to be performed: Utility Line Clearance 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 Dolicm. ♦ 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: Eagan, Lakeville, Savage Has your company ever had a license revoked in any other city? (YES) (NO), If yes,where? LICENSE FEE: $30.00 Wright Tree Service, Inc. L'L:5 Name of Business or Company COMPLETION OF THE WORKERS 5930 Grand Avenue 1 0 1 1 1 1 1 COMPENSATION INSURANCE AND Business Street Address TAX I.D.FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED. West Des Moines IA 50266 \P I I 114 THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF ( 515 ) 277-6291 THE CALENDAR YEAR WITHIN Phone Number WHICH APPLIED FOR OR UPON kpettijohn@wrighttree.com EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: 0 - 2 4014- 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 31g) 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: Wright Tree Service, Inc. Business Address: 5930 Grand Avenue West Des Moines IA 50266 City State Zip Code Minnesota Tax Identification No.: 7516994 Federal Tax Identification No.: 42-0860402 If a Minnesota Tax Identification number is not required, please explain: 4/114-ntro(4-41L- Contract Adm 11/22/13 Signature Title Date 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): American Zurich Ins Co Policy Number or Self-Insurance Permit Number: WC591265001 Dates of Coverage: 10/1/13 through 10/1/14 OR 1 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 and obligations with regards to business licenses,permits and Workers'Compensation coverage and hereby certify by my signature below that to the best of my knowledge,the information provided is true and correct. I .. rcitaxi al Wright Tree Service, Inc. Signature 4 Business Name 5930 Grand Avenue Date: 11/22/13 West Des Moines IA 50266 Business Address Telephone Number: (511 277-6291 { CITY OF OAK 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. ,hvI �j, ,y By: °�. '`' / Date / Corporate Officer or Individual Propr rship Owner i Subscribed and sworn to(,�before me this Joy` day of , ��� . klti ' +/ , Notary Public. ,I �I County. My commis;i 'ires:KELLY PETT1f011N Commission Number its 396 My Commission Expires ,o,N March 20, 2016 S:Shared/Forms/Arborist/Tree Worker's License Application AR• CERTIFICATE OF LIABILITY INSURANCE DATE 09/27/DD"3"Y) 09/27/2013 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 Sara MCWeth NAME: Y Hays Companies PHONE FAX (A/C.No.Ext): 612-333-3323 (A/C,No): 612-373-7270 80 South 8th Street E-MAIL DR amcweth ha atom anies.com ADDRESS: Y� Y P Suite 700 Minneapolis, MN 55402 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: ZURICH AMER INS CO 16535 INSURED INSURERB: AMERICAN GUAR & LIAB INS 26247 Wright Tree Service, Inc. INSURERC: AMERICAN ZURICH INS CO 40142 5930 Grand Avenue INSURERD: West Des Moines, IA 50265 ,INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 36036637 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 SUBR POLICY EFF POLICY EXP W LIMITS LTR INSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY 31,0591264901 10/01/13 10/01/14 EACH OCCURRENCE $ 5,000,000 X DAMAGE TO RENTED 500,000 _COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 15,000 X BI/PD Ded. $350,000 PERSONAL&ADVINJURY $ 5,000,000 X See Agg Below GENERAL AGGREGATE $10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 10,000,000 7 POLICY X 'EC LOC $ A AUTOMOBILE LIABILITY BAP 591264801 10/01/13 10/01/14 COMBINED SINGLE LIMIT 5,000,000 (Ea accident) $ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per accident) $ X BI/PD Ded. $ B UMBRELLA LIAB X OCCUR SXS932696700 10/01/13 10/01/14 EACH OCCURRENCE $ 15,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 15,000,000 DED RETENTION$ $ C WORKERS COMPENSATION WC591265001 (AOS) 10/01/13 10/01/14 X WCSTATU- 0TH- AND EMPLOYERS'LIABILITY TORY LIMITS ER Y/N A ANY PROPRIETOR/PARTNER/EXECUTIVE NIA WC591265301 (WI) 10/01/13 10/01/14 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? -- (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 _ Des,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Grove THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1300 South Broadway AUTHORIZED REPRESENTATIVE Oak Grove, MO 64075 9e-e...„.._„ USA ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ddebuhr 36036637 SUPPLEMENT TO CERTIFICATE OF INSURANCE DATE NAME OF INSURED: (General Liability: Per Project Agg Limit is $5,000,000, and applies when required by written contract, subject to Overall General Agg Limit of $10,000,000 SUPP(10/00)