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Only this Certificate <br /> CERTIFICATE OF INSURANCE of Insurance form <br /> Return Completed Certificate to (City) TO will be accepted <br /> This certifies to the City that the following described policies have been issued to the Insured named below and are in force at this time. <br /> Insured <br /> Address <br /> Description of operations/locations/products insured(show contract name and/or number,if any): <br /> POLICY EXPIRATION <br /> POLICIES LIMITS NUMBER DATE <br /> ANDINSURERS <br /> Workers' Compensation <br /> Employers Liability$ — <br /> (Name of Insurer) <br /> Best's Rating <br /> Check policy type: Comprehensive General Liability <br /> Occurrence $ <br /> Comprehensive General Liability Each Aggregate $ <br /> or <br /> Commercial General Liability ------------------ <br /> Commercial General Liability <br /> (Name of Insurer) Each Occurrence $ <br /> Best's Rating General Aggregate either <br /> Claims-Made or Occurrence per project/location $ <br /> or twice occurrence limit $ — <br /> Each Person Each Accident <br /> Business Auto Policy $ $ <br /> Liability Coverage Symbol <br /> Each Accident, Property Damage <br /> (Name of Insurer) or _ <br /> Best's Rating Combined Single Limit$ <br /> Umbrella Liability Occurrence/ <br /> Aggregate $ <br /> (Name of Insurer) <br /> Self-Insured Retention <br /> Best's Rating- <br /> Claims-Made <br /> ating Claims-Made or Occurrence <br /> Note: If commercial general liability insurance is used or if aggregate limits are <br /> endorsed <br /> d tot <br /> comprehensive <br /> eneral llslform, hgrgregate must apply pealon/project or <br /> the aggregate must at least twice the <br /> NEI Phase II Water and Sewer <br /> July 2007 <br /> Division IV-29 CIP Nos.7468, 7589, 7590 <br />