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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):
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 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 knowled e,the information provided is true and correct.
1 'P• Svr.,K 4/ `��,Aa-- S'— i jvtcJU
Signature Business Name
Date: S- / 3 - i y
Business Address
Telephone Number: (65/ YS=c2/ 7
1
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.
7-/3- /7 By: //.
Date Corpora e Officer or Ind'1 ual Proprietorship Owner
Subscribed and sworn to before me
this i ` day of .: , :
0
\x , Notary Public.
is I County. ", JULIE A.HULTMAN
)(1 �s� NOTARY PUBLIC MINNESOTA
My commission ex.
xpires: l I —I 5 My Commission Expires Jan.31,2015
S:Shared/Forms/Arborist/Tree Worker's License Application
Ac •® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
�•+�� 08/132014
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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the
terms and condtions 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 CONTACT
NAME: Angela M Bramucker
Burns&Wilcox,Ltd.-MN01 PHONE Fax
(A/C.No.6n0: 612-564-1880 ext.2204 (MC,No): 612-564-1881
E-MAIL
ADDRESS: ambramuckerebums-wilcox_com
333 South 7th Street,Suite 1300
Minneapolis MN 55402 q INSURER(S)AFFORDING COVERAGE NAIL*
5f 11) a INSURER :Atain Specialty Insurance Company
INSURED INSURER B:
Junker Tree Service
Bruce Junker dba INSURER C:
PO Boot 42 INSURER D:
Stillwater MN 55082 INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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
LTR INSR wVD POLICY NUMBER IMMIDD/YYYY) tMMIOD YYYY) LIMITS
GENERAL LWBLLJTY EACH OCCURRENCE $ 1,000,000
DAMAGE TO REN TED —
X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 100,000
CLAIMS-MADE X OCCUR MED EXP(Any one person) $53000
A CIP130737 04/062014 04/06/2015 PERSONAL&ADV INJURY $ 1,000,000 _
GENERAL AGGREGATE $ 1,000,000
GE 'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ INCLUDED
X POLICY PRO-
CT LOC $
AUTOMOBILE LIABILrIY COMBINED SINGLE LIMIT
�I SINGLE(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS _ AUTOS ( )
HIRED AUTOS NON-OWNED PROPERTY DAMAGE $
_ AUTOS (Per accident) _
$
UMBRELLA LAB OCCUR 'j EACH OCCURRENCE _$
EXCESS MB CLAIMS-MADE AGGREGATE $
DED I RETENTION$
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER
ANY PROPRIETOR/PARTNERIEXECU11VE��r - _ --- ___-__. E.L.EACH ACCIDENT --- $------- - — - ---
-OFFICE/MEMBER OCCLUDED?
(Mandatory In NIA E.L.DISEASE-EA EMPLOYEE $
If yes.describe under
CC-SCRIPT]ON OF OPERATIONS below E.L.DISEASE-POL CY LIMIT $
Fr
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required)
CERTIFICATE HOLDER CANCELLATION
City of Oak Park Heights SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
14168 Oak Park Blvd. AUTHORIZED REPRESENTATIVE
Oak Park Heights MN 55082 14ngeTa M. Bramucker
1 �
O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
- _
4921 D �