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<br />SECTION 00340 <br />Issue date: <br />CERTIFICATE OF INSURANCE <br />,The General Conditions of the Coritract set forth the requirements for Contractor's Liability Insurance and Workmen's <br />Compensation Insurance. <br />~Thls certUicate !s Lssued as a matter of information only and conkrs no rights upon the addressee. It does not amend, <br />extend or alter the coverage afforded by the policies Iisfed below. Contractor may submit a valid certificate of tnsuranm <br />1n place of this form 1f preferred. <br />Name and Address o[ Insured ~ ~ COMPAN[ES <br />Covering (Protect Name and Location) <br />Addressee: <br />(Owner) <br />' This is to certify that the following described policies, subJect to their terms, conditions and exclusions, have been issued <br />to the above-named Insured and are in force at this Ume. <br />"TYPE OF INSURANCE CO. POLICY EXPIRATION uMrrs OF t.IABIUlY IN THOUSANGs <br /> 'CODE NUMBER DATE ~~ . <br />1 <br />lal Workers Com <br />ensatbG OCCURRENCE AGGREGATE <br />. <br />p <br />lb) Employers UabNty SCATU'IORY <br />2. ComprrhensNt General ~ EACH ACCID6Nr <br />L1abUlty Indudlog: BODILY INJURY 6 <br />O YremLUS-0peratbns ~ UIRED 600 600 <br />O Independent Contrietors PROPERTY DAMAGE i i <br />~ ProduMS and Compkted REQUIRED I00 to <br />Opcrrtlons BODILY INJURY S i <br />d Broad Form Property Damage AND PROPERrY <br />O Contractual uabUlty DAMAGE COMBINED <br /> <br />D Explosion & Collapse <br />Ii <br />d <br />REQUIRED <br />i GOB <br />S 600 <br />arar <br />O UndergrouM Harald 'APPlJES'I'O PRODUCTS AND COMPIt'IED i <br />I] Pcrsanal In u with Em l ent <br />J ry P oYrn OPERA7[ONS FJA7MD <br />IPERSDNAL INJUart <br />P.rAUSlon 1)cleted <br /> aepnR® S 600 <br /> Bdlly NJury 8 I50 <br />3. ComprehensNe Aummoblk IF+c6 h.+oa <br />UabBlty <br />~' <br /> <br />O Owned B <br />oaur Ia1wY t <br /> fFid.OmrrtnW 600 <br />O Hked Rcyuoed i <br />O Non-Owned PmpcM1y p.o.yp t <br /> Rquaed {Soo <br /> Beam l~ywy i <br /> ..d P,wrnr <br /> ~ cembmea seo <br /> Reyutma s <br />4. Excess UablBty Beauy mJury i - <br />G Umbteila Form u+d IivpcnY <br />O Other than Umbrella D'°.g C°mb°"d <br /> Rry~v~a s I.ooo Loon <br />5. Other (Speeltyl <br />BUI[DERS R1SE <br />' I. Products and Completed Operauons wverage wgl be malntalncd for a mltllmum period of U I O 2 yraris) alter fuml payment <br />2. Has each of the above Rsted policies been endorsed to retlec[ the company's obligatlon to nott(y the addressee ta the event of can- <br />txllatlon or ran-renewal? O Yes ~ No <br />` CER'ITFICATTON <br />1 hereby cer[lfy that 1 am an authorized representative of each of the insurance companies ILsted above. and that the coverages atforded <br />order the policies listed, above will not be carrttlled or allowed to expire unless thirty 1301 days written notlce hour been given to the <br />addreascc of this eertlRrate. <br />I Name of Issuing Agency Signature oC Authorized Representatlve <br />L Address Date of Issue <br />