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CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD-BOX 2007 OAK PARK HEIGHTS,MINNESOTA 55082 RECEIVED (651)439-4439 JAN 2 31015 CITY OF OAK PARK HEIGHTS 2015 TREE WORKER'S LICENSE APPLICATION 1. 1/4-6 Date: ► Firm or Business Name: 1''ct u r S I ' s ''�1 ��� Or)l)( cetvA-rr"1'<- Type of tree work to be performed:'-e_ V?VV1(A/L( " eqk / y .1)1/1e-41-5 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: OCAVr — fi/ Q Q (C� r�a. 1 V7')e� Has your company ever had a license revoked in any other city? (YES) (NO) If yes,where?, 1�� LICENSE FEE: $30.00 NkY ree s ✓l - �X/( �f -' 1}C Name of Business or Company Su Uf1 T�Ge. COMPLETION OF THE WORKERS l01 S 11 V IA- Si COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED ttII� BEFORE A LICENSE CAN BE ISSUED. rb J'5 W l O23 THE FORMS ARE ATTACHED. City �7 J State Zip Zip Code LICENSE EXPIRES THE END OF ( 1056 l7 0 ` '7 THE CALENDAR YEAR WITHIN Phone Number WHICH APPLIED FOR OR UPON 7 V t i}1 OvI Sac)C kce‹. .c cirri EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, 9OIS -- k i 2 , j 15 WHICHEVER OCCURS FIRST. License No.TW: Date: 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 1st through December 31st) 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: 1 D 5� Girsi t o Business Address: (46 G 5� Ra be r- tNi 9-023 City , (�(,� O� State Zip Code 2J Minnesota Tax Identification No.: D 611 F Federal Tax Identification No.: ` 3 r l,� 11T If a Minnesota Tax Identification number is not required, please explain: 1(AA taillki4r4( 047Ca141( Signature Title Date • ,:e 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) eat �) (,(�(,✓� �'r'Wli( ✓Gt n Policy Number or Self-Insurance Permit Number: InAtd o2 44'722S Dates of Coverage.- 1 -14 -r 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 knowledge,the information provided is true and correct. 1l wtt Jym— PAcd4.1(4 Trams c. Signature Business Name OW.; 57"-Cr k 6aVffire - Date: 1—�5--15 (o LS 6✓1 st 41 -is on 5 623 Business Address ,yr.,-( l� Telephone Number: ✓9 37' 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. II151 JS By: Ct Date Corporate Officer or individual Proprietorship Owner Subscribed and sworn to before me this 15 day of .. GIj)Lt�lJ1.�11,( t9QJ5- (i'io.tur I ) CELESTE SMITH (it Notary Public. NOTARY PUBLIC-STATE OF NEW YORK ( No. 01SM6081995 l )t'!�}C Qn r County. Qualified In Westchester County --II 1 My Commission Expires October 21. 20.L) My commission expires:Uc;��a><k ,���;�(.t l• S:Shareo/FormsiArborlstfTrec Worker's License Application A`,°RO® - CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYW) 1/16/2015 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 CONTACT CT drew Frano I First Niagara Risk Management, Inc PHCN F:tl: (716)819-5500 I((A/C.Nok'(716)819-5140 726 Exchange Street Suite 900 DRESS:andrew.frano @fnrm.com INSURERS)AFFORDING COVERAGE NAIC# Buffalo NY 14210 INSURERANatl Union Fire Ins Co of Pitt 19445 INSURED INSURER B New Hampshire Insurance Company 28341 . Nature's Trees, Inc. INSURER C Great American Insurance 22136 dba SavaTree/Save-A-Lawn INSURER D: 550 Bedford Road INSURERE: Bedford Hills NY 10507 INSURERF: COVERAGES CERTIFICATE NUMBER:14-15 _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 POLI CIES.LIMITS SHOWN MAY HAVE BEEN REDU CED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR MD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000 1 DAMAGE TO RENTED 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) ,$ A CLAIMS-MADE F31 OCCUR X X 7267137 7/1/2014 7/1/2015 MEDEXP(Anyoneperson) $ 10,000, X XCU INCLUDED PERSONAL&ADV INJURY $ 1,000,000 X BLKT. CONTRACTUAL GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 7 POLICY I X I 78-F n LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 2,000,000 A X ANY AUTO BODILY INJURY(Per person) $ x ALLOVMNED SCHEDULED x x 3500769 (MA) 7/1/2014 7/1/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OVuNED AUTOS 3500770 (AOS) PROPERTY DAMAGE (Per accident) $ — X $250 COMP X $250 COLL PHYSICAL DAMAGE $ A.C.V. X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 20,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 20,000,000 DED X I RETENTION$ 10,000 X X BE 044156600 7/1/2014 7/1/2015 $ B WORKERS COMPENSATION X X I TORY LIMITS I I OER AND EMPLOYERS'LIABILITY - - ANY PROPRIETOR/PARTNER/F_XECUTIVE Y/N 1,000,000- E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N NIA 018962586 7/1/2014 7/1/2015 (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 CONTRACTOR'S EQUIPMENT MACO247225 7/1/2014 7/1/2015 LEASED/RENTED $250,000 ($10,000 Deductible) SCHEDULED $3,503,931 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Mach ACORD 101,Additional Remarks Schedule,if more space Is required) RE: Tree Removal, Pruning and Treatments City of Oak Park Heights is an Additional Insured on a primary and non-contributory basis in regard to the above Liability policies when required by executed written contract. A Waiver of Subrogation is included when required by executed written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Oak Park Heights ACCORDANCE WITH THE POLICY PROVISIONS. 1 PO Box 2007 Oak Park Heights, MN 55082 AUTHORIZED REPRESENTATIVE M Bonetto/AFRANO ° -�-�� ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSO25/7mnn5l m The.artnor1 name and Innn are.re.nicfe.re.rl marks of A(^.ARn A °RD CERTIFICATE OF LIABILITY INSURANCE 6/23/o� ) 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 CONTACT Andrew Frano NAME: First Niagara Risk Management, Inc (P,qH/C dQ F,,". (716)819-5500 I(FA7( Na(716)819-5140 726 Exchange Street Suite )00 RECEIVED ADDRE!S;andrew.frano@fnrm.com Mt INSURER(S)AFFORDING COVERAGE NAIC 8 Buffalo NY 14010 INSURE tA:Zurich American Insurance Co. 16535 INSURED INSURE tBAmerican Guarantee & Liability 26247 Nature's Trees, Inc. JUL — I(I n�q! INSURE t C:Great American Insurance Co. 22136 dba SavaTree/Save-A-Lawn INSURE t D: 550 Bedford Road INSURE t E: City of Oak Park Heights Bedford Hills NY 10507 AM fREtF: COVERAGES CERTIFICATE NUMBER:15-16 REVISION NUMBER: T:113 :3 TO CERTiFY iFT 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 POUCY EFF POLICY EXP UNITS JM W SR VD POLICY NUMBER (MM/DDIYYYY) (MMIDD/YYYY) GENERAL LUIBIUTY EACH OCCURRENCE $ 1,000,000 GE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 1,000,000 A I CLAIMS-MADE X OCCUR X X GLO 0381388 7/1/2015 7/1/2016 MEDEXP(Anyoneperson) $ 10,000 X XCU INCLUDED PERSONAL&ADV INJURY $ 1,000,000 X BIM. CONTRACTUAL GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 Ti POLICY)X FM" Ti LOC $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT _ (Ea accident) $ 2,000,000 X ANY AUTO BAP 0381389 BODILY INJURY(Per person) $ A x ALL OWNED SCHEDULED X X 7/1/2015 7/1/2016 AUTOS ,_ AUTOS BODILY INJURY(Per accident) $ X NSWNED PROPERTY DAMAGE $HIRED AUTOS AUTOS I (Per accident) X $250 COMP X $500 COLL PHYSICAL DAMAGE $ A.C.V. X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 20,000,000 B EXCESS UAB CLAIMS-MADE AUC 0178816-00 AGGREGATE $ 20,000,000 DED I X I RETENTION$ 10,000 X X 7/1/2015 7/1/2016 $ A WORKERS COMPENSATION X X I TQRY I IA ITS I I OFR AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC 0381387 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? © NIA 7/1/2015 7/1/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below _____.E L DISEASF-POL!CYIIMa z$ 1>00-0,000----- - C CONTRACTOR'S EQUIPMENT CO247225 7/1/2015 7/1/2016 LEASED/RENTED $250,000 ($10,000 Deductible) SCHEDULED $3,503,931 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: Tree Removal, Pruning and Treatments City of Oak Park Heights is an Additional Insured on a primary and non-contributory basis in regard to the above Liability policies when required by executed written contract. A Waiver of Subrogation is included when required by executed written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Oak Park Heights ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 2007 Oak Park Heights, MN 55082 AUTHORIZED REPRESENTATIVE , _ --5:„.-- .. =-.t°�-- • r r M Bonetto/AFRANO „�" • ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 t7ninof1 ni Th.ArtARf namo and Innn aro roniefarard marlre of ACARfl AcG CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) `..----" 10/21/2015 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 CONTACT Andrew Frano NAME: First Niagara Risk Management, Inc mat,Extl: (716)819-5500 FAX (PJC. 1716)819-5140 726 Exchange Street Suite 900 ADDRIESS:andrew.frano@fnrm.com INSURER(S)AFFORDING COVERAGE NAIC# Buffalo NY 14210 INsuRERA:Zurich American Insurance Co. 16535 INSURED INsuREReAmerican Guarantee & Liability 26247 Nature's Trees, Inc. INSURER C:Great American Insurance Co. 22136 dba SavaTree/Save-A-Lawn INSURER D: _ 550 Bedford Road INSURER E: - Bedford Hills NY 10507 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 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 1ADDL SUBR POLICY EFF POLICY EXP UMITS LTRINSR WVD POLICY NUMBER ,(MM/DD/YYYY) (MM/DDIYYYY) GENERAL UABIUTY EACH OCCURRENCE _ $ 1,000,00Q. X COMMERCIAL GENERAL_LIABILITY o DAMAGE TO RENTED PREMISES(Ea occurrence) $ 1,000,000 ! A CLAIMS-MADE n I OCCUR X X GLO 0381388, 7/1/2015 7/1/2016 MED EXP(Any one person) $ 10,000 XX_CU INCLUDED __ PE_RSONAL&ADV INJURY $ 1,000,000 X BLKT. CONTRACTUAL GENERAL AGGREGATE $ 2,000,000 _GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG_ $ 2,000,000 POLICY X jF T LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 _ (Ea accident) $ 2,000,000 A X ANY AUTO SAP 0381389 BODILY INJURY(Per person) $ X ALL OWNED SCHEDULED _ AUTOS AUTOS X X 7/1/2015 7/1/2016 BODILY INJURY(Per accident) $ _ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ _ AUTOS (Per accident) X $250 COMP X $500 COLL _ PHYSICAL DAMAGE $ A.C.V. X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 20,000,000 B EXCESS UAB CLAIMS-MADE AUC 0178816-00 AGGREGATE - $ 20,000,000 DED X RETENTION$ 10,001 X X 7/1/2015 7/1/2016 $ A WORKERS COMPENSATION I XyWC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N MC 0381387 E.L.EACH ACCIDENT $ 1,000_,000 OFFICER/MEMBER EXCLUDED? N N/A 7/1/2015 7/1/2016 —` (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below _ _ y _ ____ _ .E.L_DISEASE-POLICY LIMIT $ 1,000 000 C CONTRACTOR'S EQUIPMENT MACO247225 7/1/2015 7/1/2016 LEASED/RENTED $250,000 ($10,000 Deductible) SCHEDULED $3,503,931 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 on a primary and non-contributory basis in regard to the above Liability policies when required by executed written contract. A Waiver of Subrogation is included when required by executed written contract. • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Oak Park Heights ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Blvd N Oak Park Heights, MN 55082 AUTHORIZED REPRESENTATIVE M Bonetto/AFRANO r^ "� •.-, 3�_�f__rte' ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 onions:nt Tha AfrflRrl name arid Inn"arc ranietcrarl marke of Ar:rlPll