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HomeMy WebLinkAboutJoe Cardin dba JCE Tree Service RECEIVED "W's CITY OF OAK PARK HEIGHTS MAR 3 0 14168 OAK PARK BOULEVARD-BOX 2007 2015 OAK PARK HEIGHTS,MINNESOTA 55082 (651)4394439 C'h'of Oak pant Neches PM CITY OF OAK PARK HEIGHTS 2015 ii TREE WORKER'S LICENSE APPLICATION Date: 3 -l s Firm or Business Name. _ , I ,.. t P Q ,' •LG i_ 9A)/(--€., Type of tree work to be performed: 1 :► .V I .1 _ / ./l. ;`/f o 4 u 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: I ., IA) 1 1. Has your company ever had a license revoked in any other city? (YES) If yes,where? LICENSE FEE: $30.00 (,' /J. r. ■-•ab Z.E Name of Business or Company _ 5)j5) I5 or COMPLETION OF THE WORKERS (� GId _ 01'16 COMPENSATION INSURANCE AND Business Street Ad ss TAX I.D.FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED. � f 1/f7 (LJC 6/4693 THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF (�L5 ) ��- ()i-79 THE CALENDAR YEAR WITHIN Phone Number WHICH APPLIED FOR OR UPON - �! / ► , . ,A EXPIRATION OF LIABILITY ail Address INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: c 0 1 5 1 3 3 -3045 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 31St) Personal Information: (Complete only if applicable) Applicant's Name: ( - in Applicant's Address: � �9341 C oe f f toga 'City State Zip Code Social Security No.: C l f c/ zD tPLI q Business Information: (Complete only if applicable) Business Name: fir/ __ 6 �� • PC wt);ce Business Address: ,C-X 5 abou'Q, City W5H0C6 State Zip Code Minnesota Tax Identification No.: Federal Tax Identification No.: 07{ If a Minnesota Tax Identification number is not required,please explain: /S* Title Date Os 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 •Com an not the Insurance ent : S If _p y( ae ) aim its,. " ,l'it '. r)1 Policy Number or Self-Insurance Permit Number: _ -;J?- Al - a ;:# I rG Dates of Coverage: f ��Q/1_/ c-i--,1- �1,L5 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. r-- e •. ness Na e alum' AL. iko 1111 3" O 7 1: MOM? . [. 1 �. / 0 ._ usiness Address Telephone Number:- 79/yap- ( )17q it 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 b not limited to attorney fees and costs incurred relative to such claims and losses. Celd<‘/) Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this a/I-1 day of r , a.ois . Ortr'l liV` to 1 aliFirir ) , Notary Public. -° County.6(ii eO ' �) My commission expires: 1//e/d,v/7 S:Shared/Forms/Arborist/Tree Worker's License Application .,.�""'1 JOECA-2 OP ID: BS 4 RD; CERTIFICATE OF LIABILITY INSURANCE 03/25IDD/YYYYi 03125!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(les)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 Phone:715-425-0159 caftiTAct PHONE Leitch 4 EPine St Agency,Inc. •6438 rag'em: I FAX c.No): P O Box 65 REC IVED ADDRESS: • River Falls,WI 54022 Betty J.Skelton INSURER(S)AFFORDING COVERAGE NAIL ' INSURER A:NSI/West Bend Mutual INSURED Joe Cardin En sea INSURER S:Auto Owners Ins.Co. 18988 JCE Tree - 234 Cty Rd JJ INSURER c River Falls,WI 22 INSURER D: City of Oak Park Heights INSURER E: —_____"__AM..._________PM 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE_.------___.__ R tWO POLICY NUMBER (NWDDIYYYY) (MNWDD/TYYY UNITS GENERAL LWSLITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY NSU1098332 05/15/2014 05/1512015 DAMAGE TO RENTED PRE(NISES(Ea ocowrsnci_ I S 100,000 CLAIMS-MADE X OCCUR I MED EXP My one person) $ 6,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 1 GEM.AGGREGATE LIMIT APPLES PER: PRODUCTS-COMP/OP AGG_ $ 2,000,000 7 POLICY F jE- n LOC $ AUTOMOBILE LIABILITY C (Ea accident)OMBINED SINGLE LIMIT $ 500,000 B ANY AUTO 4712167501 07/01/2014 07/01/2015 BODILY INJURY(Per person) $ ALL ALT OWNED X SCHEDULED BODILY INJURY(Per accident) $ HIRED AUTOS X �OSWIED (Per DAMAGE $ $ UMBRELLA LAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ _ DED 1 RETENTIONS — $ WORKERS COMPENSATION I WC STATU- OTH- AND EMPLOYERS'INABILITY y i N TORY LIMITS . ER- ANY PROPRIETOR/PARTNER/EXECUT VE E.L.EACH ACCIDENT $ OFFICER/MEMER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S ryes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB S I DESCRIPTION OF OPERATIONS I LOCATIONS I VEIECLES (Attach ACORD 101,Additional Remarks Schedule,it more space Is required) All policy provisions apply. Workers camp certificate will follow from that carrier. CERTIFICATE HOLDER CANCELLATION CITYOAI 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 14168 Oak Park Blvd N AUTHORIZED REPRESENTATIVE Oak Park Heights,MN 55082-2007 Betty J.Skelton I �� 0 1988-2010 ACORD COR TION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD DATE(MM/DDYYY) ACCORD NCERTIFICATE OF LIABILITY INSURANCE 3/25/2015 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 tem)s 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). iw' PRODUCER RECEIVED NAME: Berkley Risk Administrators,LLC Leitch Insurance Agency Inc No.): C.No.Ext): 888 548-7431 I (Ar (866) 215-8118 PO Box 85 E-MAIL (Arc ADDRESS: PolicyServices @berkleyrisk.com River Falls,WI 54022 MAR 3 0 2015 INSURER(S)AFFORDNG COVERAGE NAIL# INSURER A: Minnesota Workers'Comnencatien Assigned Rick 9991 INSURED INSURER B: Joe Cardin Enterprize LLC INSURER C: 234 County Road JJ City of Oak Park Heights INSURER D: River Falls,WI 54022 PM INSURER E: 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD _(MM/DD/YYYY) (MM/DD/WW)_ GENERAL LIABILITY AUTOMOBILE LIABILITY $ E R COMPENSATION WC STATU- OTH- AND WORKERS EMPLOYERS'LIABILITY Y/N X TORY LIMITS ER AND ANY PROPRIETOR/PARTNER/EXECUTIVE LTA E.L EACH ACCIDENT $ 100,000 A OFFICE/MEMBER EXCLUDED? N/A ❑ WC-22-04-218027-02 08/04/2014 08/04/2015 (Mandatory In NH) E.L. DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below _ E.L. DISEASE-POLI CY LIM IT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACO RD 101,Additional Remarks Schedule,if more space is required) Coverage Election Category Elect.Status Name State(s) All Entities/Locations Officer Exclude Joe Cardin MN Joe Cardin Enterprize LLC MN Payroll, MN 00000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City Of Oak Park Heights AUTHORIZED REPRESENTATIVE 14168 Oak Park Blvd Box 2007 Oak Park Heights, MN 55082 Signature: ACORD 25(2010/05) BRAC 3139 �.....,41 JOECA-2 OP ID:BS A RID CERTIFICATE OF LIABILITY INSURANCE DATE 0/1/2015 ) 10121/2015 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 POUCIES 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 pollcy(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 Phone:715-425-0159 ?Arm 1 Leitch Insurance Agency,Inc. 174E Pine St Fax:715-425-6439 ,PNON ,E). I ,No): P O Box 85 ADDRESS: River Falls,WI 64022 Betty J.Skelton INSURERS)AFFORDMG COVERAGE NAC N _ INSURERA:NSUWest Bend Mutual INsuna° Joe Cardin Enterprises muses B:Auto Owners Ins.Co. 18988 JCE Tree INSURER C: 234 Cty Rd JJ ...._...---- River Falls,WI 54022 INSURED: INSURER E: -- • 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iNsR ADM SUBR POLICY EXP LTR TYPE OF INSURANCE MR sulfa POLICY NUMBER (RNAIDJYYYYI IM D/TYYY), LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A j X COMMERCIAL GENERAL LIABILITY X NSU1098332 05/1512015 05/1512018 DAMAGETO RENTED ,00.0 PREMISES tEe aopgrpld») $ t00,OtM1 1 CLAIMS Di]OCCUR MED EXP(My one parson) 5 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 j GEN'L ( AGGREGATENM LT APPLIES'�IPER: I PRODUCTS-COtiPIOP AGG $ 2,000,000 POLICY`GI'm i l LOC $ AUTOMOBILE UABL/TY - EaCOMBME SINGLE LIMIT ¢ 500,000 sodden° B I ANY AUTO 4712187501 1 07101/2015 07/0112016 BODILY INJURY(Par pweon) $ AUTOS OWNED ! SCHEDULED BODILY INJURY(PK ao Id rlt) $ `X NON-OWNED • ( -PROPERTY DAMAGE $ I— aL/ros • (Per HIRED AUTOS $ • UMBRELLA UABi OCCUR E• ACH OCCURRENCE $ EXCESS ME CLAIMSMADE • AGGREGATE _ $ DEC RETENTION$ $ WORKERS COMPENSATION I • • • �l WC STATU- i OTH A AND EMPLOYERS'LIABILITY Y/N . TORY Mini. ANY PROPRIETORIPARTNERIEXECUTTVS E.L.EACH ACCIDENT $ OFFICER/HEWER EXCLUDED? N/A (Mandatary In NII) E.L.DISEASE-EA EMPLOYEE $ N du. 1bo under DESCRIPTION OF OPERATIONS below ELL DISEASE-POLICY LMT $ # • DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If mare space l• e required) All policy provisions apply. The City of Oak Park Heights is added as additional insured relative to liability that may arise out of actions taken by the named insured. Workers comp certificate will follow from that carrier. CERTIFICATE HOLDER CANCELLATION C,)TYOA1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BE City of Oak Park Heights CCO ACCORDANCE IMTHRATIONDT Pa PROVISIONS.THEREOF, NOTICEATE L DELIVERED IN PO Box 2007 14168 Oak Park Blvd N AUTHORRED REPRESENTATIVE Oak Park Heights,MN 55082-2007 Betty J.Skelton tezte , 1 C...� j 61988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD • DATE(WIDOW YYY) �iccRb CERTIFICATE OF LIABILITY INSURANCE ." 10/22/2015 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. II 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 ER CONTACT Agency Inc NAME Berkley Risk Administrators,LLC PO Leitch Insurance 85 PHONE C No EA): 888 548-7431 FAX Ne.) (866) 21 5-81 18 BoxE-MAIL ADDRESS: Policpervices@berkleyrisk.(Dom River Falls,WI 54022 INSURER(SI AFFORDING COVERAGE NAIL INSURER A: Minnesota Workers'Compensation Assigned Risk P INSURED INSURER B: Joe Cardin Enterprize LLC -- -----_.- ,_ INSURER C: 234 County Road JJ INSURER D: River Falls,WI 54022 INSURER E 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 TI-E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TIE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. It.S R ,ADDI. SUBR POLICY EFE POLICY EXP TYPE OF INSURANCE POLICY NUMBER LIMITS 'TR INSR WVD (MM!DD-YYYY) (Ntt DDIYYY?) --_-. AL -.__._ .......... G£NERAL L(ABILITY AUTOMOBILE LIABILITY • $ • WORKERS COMPENSATION • WC ST AT U- OTH- AND EMPLOYERS'LIABIL ITT YIN • TORY LIMITS ER ANY PROPRIETOR%PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICE/MEMBER EXCLUDED? NIA WG-22-04-218027-03 08/04/2015 i08/04/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 II yea,describe under •• DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101.Additional Remarks Schedule,II mote space isrequired) Coverage Election Category Elect.Status Name State(s) All Entities/Locations Officer Exclude Joe Cardin MN Joe Cardin Enterprize LLC MN Payroll, MN 00000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City Of Oak Park Heights AUTHORIZED REPRESENTATIVE 14168 Oak Park Blvd Box 2007 Oak Park Heights, MN 55082 �- Signature: ~' ACORD 25(2010/05) BRAG 3139 CUSTOMER NO. 0110311585 "WEST BEND UTUAL INSURANCE COMPANY' West Bend Mutual Insurance Company R N41 ✓ 1900 S.18th Avenue!West Bend,WI 53095 POLICY NUMBER: NSU 1098332 06 ENDORSEMENT EFFECTIVE OCT. 21, 2015 ADDING ADDITIONAL INSURED ON LIABILITY COMMERCIAL GENERAL LIABILITY ADDITIONAL INTEREST CITY OF OAK PARK HEIGHTS PO BOX 2007 OAK PARK HEIGHTS, MN 55082 VARIOUS LOCATIONS RECEIVE FORM CG2026 APPLIES DESIGNATED PERSON OR ORGANIZTN ADDITIONAL INSURED HAS BEEN ADDED City of Oak Park Heights ANI P'A INSURED: JOE CARDIN ENTERPRISES JOE CARDIN DBA 234 COUNTY ROAD JJ RIVER FALLS, WI 54022 AGENCY: LEITCH INSURANCE AGENCY INC 48-563 POLICY PERIOD FROM: MAY 15, 2015 TO: MAY 15, 2016 ISSUED 10/29/15 ADDL INTEREST COPY t THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)Or Organization(s) Information required to complete this Schedule, if not shown above,will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organi- zation(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1