HomeMy WebLinkAbout4H - Haultech Refuse Hauling
STAFF AGENDA REPORT
AGENDA #:
PREPARED BY:
SUBJECT:
DATE:
4 (H)
LAURIE DAVIS-FRIEDGES
APPLICATION FOR REFUSE HAULING FROM HAULTECH
ENVIRONMENTAL
FEBRUARY 5, 1996
INTRODUCTION: Haultech Environmental of Savage, Minnesota is applying for a Refuse
Hauling License in order to operate in the City of Prior Lake.
BACKGROUND: Haultech Environmental has submitted all of the necessary forms,
applications, insurance and fees for a Refuse Hauling License.
DISCUSSION: The Prior Lake Police Department is currently running a background
check on Haultech Environmental and will submit that information to me
before license approval. Scott County Environmental Health Agency has
verified that Haultech Environmental is currently licensed through Scott
County and meet all requirements for licensing.
ALTERNATIVES:
1.
Prior Lake City Council approve Haultech Environmental's
Refuse Hauling License pending Police Department background
check.
Prior Lake City Council may table this application for a later date.
2.
RECOMMENDATION: Staff recommends the Prior Lake City Council approve this application
pending Police Department check.
/ otion and second to approve as part of the Consent Agenda.
-1-
16200 Eagle Creek Ave. S.E., Prior Lake. Minnesota 55372-1714 / Ph. (612) 447-4230 / Fax (612) 447-4245
AN EQUAL OPPORTUNITY EMPLOYER
-----,----,......"".~< ,"",.~.. ....._..."'~".., ,....._.<'-".,""..-,~.-._-"'--,.~.,,_.~.~--"'-_....._._..,.--'-,~-
T
r
C r TY OF PHIon LAKL
/~
C IJEW -.
H. - --
462~ Dakota Street SL * PO ~>x J~~
Prior Lake, Minnesota ~~j72
APPLlCATlOI~ FOR A GARI3AG[ & HEFUSE HAULING LlCEt~SE
Ordinance 1172-2
Applicant Hau) -1:cl E"YU)/r~flfkJ..L
License Numbers
Truck Make
TraiJJM t~ake
,
Manager's name if different than applicant
'DtUVL ~'r h..u"
Firm Name H W - kh.. J; VI. U ; r 0 I'\.. I'Yt.4M.-M
Address 7~75 LJ I-/wy /3 S/J:+~ I
3lL\J~j ~, Y'r\.l-\. ~S-3 7 g
Telephone Number to I~ - ~90 - 9fo/ t
Receipt Number
License Number
l.~
2. YA-~'~31
J1A-C.K /qq"
rnact-' /9fl
3.
4.
5.
J
6.
License Fee: First Truck $125.001
Each Additional Truck 25.001
Roll Off Containers 25.00i';:::'-I_ ., _c-~
Charge per residence per year for once a week pickup
Cha~ge per residence per quarter for once a week pickup
Charge per residence per month for once a week. pickup
Charge for commercial per year for twice a week pickup
Char~e on a call basis only S to
Other
PROPOSED CHANGES IN CHARGES DURING THE LIFE OF THIS APPLICATION MUST BE SUB~lITTED TO THE CITY.
Contents of (Maximum Number) dumpsters 1 cubic yard or larger will be picked up
per stop at each commercial establishment or apartment house.
Amount of materials to be picked up at residence once a week in terms of number of garbage
receptacles and refuse:
Days which your trucks will pick \lP in the City:
Number of customers: ~1lL YJ . .. -_:.
Time of day pickup will be made: ~n1 ~fzur~ to
INSURANCE POLICY (OK COpy) MUST uE ATTACHED TO THE APPLICATION.
A CERTIFIED BONO IN THE SUM OF $1,000.00 FOR EACH
I
V~SUHANCE l.tUST aE prWVIDF]) TO CO\'F.f\ :\LL VFH'CLES:
VEHICLE MUST BE FILED WITH THIS APPLICATION.
tHnimum S 100,000.00 each person insured
300,000.00 each accident
2~.,000.00 property damaye
-
I ~
There shall be no hauling in the City for hire from residential dwelling units between
the hours after 7:00 Pr.1 or before 7:UO N1 on any day. There shall be no garbage or
refuse pickup from residential dwelling unit residerlces on Sunday. Refuse and garbage
from residential areas may be picked up from one place at around level adjacent to the
street or alley, but deposited off the traveled roadway.
I (we) hereby agree to operate such business in accordance with the laws of Minnesota
and the ordinances of the City of Prior Lake. The foregoing statements are true and
correct to the best of my knowledge and belief.
FIRM NAME H 0.."'/- -r;..J. I?ro.u :'k.J L--=-
YOUR AUTHORIZED SIGNATURE ~~__ r
POSIT I UN C h.:..e-P rn tUt-tUt c.-Y', CE'O
DATE ///'7/",-
Approval by City Manager:
Approved
Approval of City Council
PROOF OF WORKERS' COMPENSATION INSURANCE COVERAGE
Minnesota Statute Section 176.182 requires every state and local licensing
agency to withhold the issuance or renewal of a license or pennit 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, Subd. 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 put in their company
file. It will be furnished, upon request, to the Department of Labor and Industry
to check for compliance with Minnesota Statute Sec. 176.181, Subd. 2.
This information is required by law, and licenses and permits to operate a
business may not be issued or renewed if it is not provided and/or is falsely
reported. Furthermore, if this information is not provided and/or falsely
reported, it may result in a $1,000 penalty assessed against the applicant by the
Commissioner of the Department lof labor and Industry payable 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 Name: ~ ~.,~~h-./.
(NOT the insurance agent~ ~
Pol icy Number or Sel f- Insurance Permit Number: -D ~ 3 Lf4fo<g-::s <1 a ,_
Dates of Coverage: ff:301 qS g/'50/9b
(or)
I am not required to have workers' compensation liability coverage because:
( 1 have no employees covered by the law.
( Otner (Specify)
1 HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WITH
LI!;ENSES[;;;;;.PERMITS AND WORKERS.' COMPENSATION COVERAGE,
~FORMAT~PROVIOED IS TRUE AND CDRRE .
ll/~-;:~
REGARDS TO BUSINESS
AND I CERTIFY THAT THE
JAllc (J) 7/87
. .
LICENSE QUESTIONNAIRE
NAME OF ESTABLISHMENT f/QJ - ~G.k FhV:l"ot\.~J,J
TYPE OF LICENSE "Re..(!""u OJJJ. l2.il1J~)
TYPE OF OWNERSHIP L.Le
NUMBER OF EMPLOYEES 4
NAMES OF EMPLOYEES
'VtU\A. -rlAV'~
-g~~
~4,?Nclu k.
-g,'11 ~SM
BIRTH DATES
~ Is()!s~
1/3/5"'1
Y//7/49
/0/9/SI
NAME OF MANAGER
1) CU\.A.. -r;:r-~
NAMES OF OWNERS
~IM.Cl -r ~ IJK'
Please return to:
C1 ty of Prier Lake
4629 Dakota Street SE
P.O. Box 359
Prior Lake, Minnesota 55372
. .
...
~orm SP:CI
LICENSE APPLICANT:
Pursuant to Minnesota Statute 270.72 1ax Clearance: Issuance of Licenses.
the licensing autnority is required to orovide to the Minnesota
Commissioner of Revenue your Minnesota business tax Identification numoer
and the social security numoer of each 1 icense aool icant.
Under tne Minnesota Government Data Practices Act and the Federal Privacy
Act of 1974, we are required to advIse you of the fol lowing 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 del inQuent taxes, penalties or interest;
2. Upon receiving this information, the licensing authority wil I
supply it only to the Minnesota Decartment of Revenue. However,
under the Federal Exchange of Information Agreement the .
Deoartment of Revenue may supply this information to the Internal
Revenue Service:
3. Failure to supply this information may jeopardize or celay the
processing of your licensing insuance or renewal appl ication.
Please supply the forlowing information and return" along with your
application to the agency issuing the 1 icense. 00 NOT RETURN TO THE
DEPARTMENT OF REVENUE.
LICENSE BEING APPLIED FOR OR RENEWED:
Z~.. .. 'kl....'f,J.. ;hJij--
Sctflt ~UAty
issuing license)
LICENSING AUTHORITY:
(name of city, county or state agency
LICENSE RENEWAL DATE:
PERSONAL INFORMATION (if applicable):
7)11.111 It -r::v. /1A..V'
7~ 75"'" W IIwy
Sa.u~'PJ
Ci~y
Soe i a 1 Se:-.;r i ~y N:..;~==:-: ~ 7,< - G:. ~ - /t:,?~t
Apoi icant's Name:
/3
)
YhYL
SU.;-f-L /
Apol ican~'s Aeeress:
55"'3 '7 ~
S-:a~e
:io Coee
BUSINESS INFORMATION
Business Name:
(if appl icable):
II~- 7:c1
7t'475"' UJ. Hw}/13
S Q..u,,-, ;~ I
City
~ :-1-12 /
~"'.
State
..5S~75?
Zip Cooe
Business Accress:
Minnesota Tax Icentification No.:
Federal Tax Ioentification No.:
;<;2 / to 0,5"3
~llg/707;)""
if a Minnesota Tax Identification number is not reauirec, please explain
on
L.d~
Position (Officer. Par~ner. e~c.) Da~e
".
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Gt&\T AlVERlC~ INSURMlCE COMPANY
LICENSE BOND
BOND NO. 7 58 38 17
KNOW ALL MEN BY THESE PRESENTS that we, HAUL TECH ENVIRONMENTAL
7675 W. HWY 13, STE 1
SAVAGE, MINNESOTA 55378
as Principal,
and GREAT AMERICAN INSURANCE COMPANY, a corporation organized under the laws of the State of Ohio, as Surety,
are held and firmly bound unto CITY OF PRIOR LAKE
as Obi igee,
in the sum of FOUR THOUSAND AND NO/100-----------------------------Dollars ($
4,000.
),
lawful money of the United States of America, to be paid unto the said Obligee or its successors; for which payment, well and
tru Iy to be made and done, we bind ourselves, our successors and assigns, jointly and severally, firmly by these presents.
Signed, sealed and dated JANUARY 12, 1996
WH E R EAS, the said Principal now has or will be granted a License or Perm it to engage in the business of
GARBAGE HAULER
in the CITY OF PRIOR LAKE
NOW, THEREFORE, the condition of this obligation is such that if the said Principal shall faithfully comply with all
laws, ordinances, rules and regulations pertaining to such License or Permit and shall indemnify and save harmless the Obligee
from all loss or damage that the Obligee shall suffer by reason of the said Principal's failure to comply with said laws,
ordinances, rules and regulations, then this obligation to be void; otherwise to remain in full force and effect.
PROVIDED, that the Surety may terminate its liability hereunder at any time by giving thirty (30) days written notice
of such term ination sent through the United States mail to the Obligee.
The term of this bond shall be from JANUARY 12, 1996
ro JANUARY 12, 1997
HAUL TECH ENVIRONMENTAL
BY- /~ L-I"h","~~
'-./ Principal
GREAT AMERICAN INSURANCE COMPANY
By j!Jrwi([ / J~.
Meredith F. Shian Attorney-in-fact
F.9515D (License or Permit Bond}- 9/77 Printed in U.S.A.
STATE OF MINNESOTA
COUNTY OF RAMSEY
55:
On .T~N[J~RY 12. . 19 q6 , befol-e me. (1 HotCll~Y Public \.lithin and for said County
and State. personally apr>eared Meredith F. Shian . _ kno...m to me to be the ^ttorney-
in-Fact of GREAT Al"lERICAN INSURANCE COMPANY ___' the corporation described in
and that executed the \oJithin and fOI"C?goin9 insll"Ument and known to lIIe to lJe the person who
executed the said instrument in behJ1f of slIid c()rpol~i1Lion und he duly acknowledged to me
that such corporation executed the same.
__~&t1..
t .
<rtEr\T AMRlC~ INSURANCE COMPANY
580 WALNUT STREET. CINCINNATI, OHIO 45202.513-369-5000. FAX 513-723-2740
The number of persons authorized by
this power of attorney is not more than
FOUR
No.O
15743
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That the GREAT AMERICAN INSURANCE COMPANY, a corporation organized
and existing under and by virtue of the laws of the State of Ohio, does hereby nominate, constitute and appoint the person or persons named below
its true and lawful attorney-in-fact, for it and in its name, place and stead to execute in behalf of the said Company, as surety, any and all bonds,
undertakings and contracts of suretyship, or other written obligations in the nature thereof; provided that the liability of the said Company on any
such bond, undertaking or contract of suretyship executed under this authority shall not exceed the limit stated below.
Name Address Limit of Power
MEREDI'm F. SHIAN NATHAN J. ESPE ALL OF ALL
EARL R. IARSON SUSAN M. SULLIVAN MINNEAPOLIS, MINNESarA UNLIMITED
This Power of Attorney revokes all previous powers issued in behalf of the attorney(s)-in-fact named above.
IN WITNESS WHEREOF the GREAT AMERICAN INSURANCE COMPANY has caused these presents to be signed and attested by
its appropriate officers and its corporate seal hereunto affixed this 25th day of October ,19 94
Attest GREAT AMERICAN INSURANCE COMPANY
STATE OF OHIO, COUNTY OF HAMILTON - ss:
On this 25th day of October, 1994 , before me personally appeared GARY T. DUNBAR, to me
known, being duly sworn, deposes and says that he resided in Cincinnati, Ohio, that he is the President of the Bond Division of Great American
Insurance Company, the Company described in and which executed the above instrument; that he knows the seal: that it was so affixed by authority
of his office under the By-Laws of said Company, and that he signed his name thereto by like authority.
This Power of Attorney is granted by authority of the following resolutions adopted by the Board of Directors of Great American
Insurance Company by unanimous written consent dated March I, 1993.
RESOL VED: That the Division President, the several Division Vice Presidents and Assistant Vice Presidents. or anyone of them, be
and hereby is authorized, from time to time, to appoint one or more Attorneys-Tn-Fact to execute on behalf of the Company, as surety, any and all
bonds, undertakings and contracts of suretyship, or other written obligations in the nature thereof; to prescribe their respective duties and the
respective limits of their authority; and to revoke any such appointment at any time.
RESOL VED FUR THER: That the Company seal and the signature of any of the aforesaid officers and any Secretary or Assistant
Secretary of the Company may be affixed by facsimile to any power of attorney or certificate of either given for the execution of any bond,
undertaking, contract or suretyship, or other written obligation in the nature thereof. such signature and seal when so used being hereby adopted by
the Company as the original signature of such officer and the original seal of the Company, to be valid and binding upon the Company with the
same force and effect as though manually affixed.
CERTIFICA TION
I, RONALD C. HAYES. Assistant Secretary of Great American Insurance Company, do hereby certify that the foregoing Power of
Attorney and the Resolutions of the Board of Directors of March 1, 1993 have not been revoked and are now in full force and effect.
Signed and sealed this 12th
day of JANUARY
,19 96
SI029P (4/93)
ALEXANDER &: ALEXANDER MPLS
4000 W OLSON MEMORIAL HWY
PO BOX 1360
MINNEAPOLIS, MY 55440-1360
~~~~;~~~;f;~;~~~;~*~~~~~~~~:;~:~:;J~~{1~~~~;~:~;;~'!':i::~;r::;;~:~:::f::~~:i;;::::~:~:.~~:::~:;:~~;~:~ ':~;;;~;~;>:;~~~ ~!t:"':~;..:;t~:::::~~::::::~::::::;::: ::::::::::;::~::::::~:::::::;::;::::::::::::;:::::::;:::~:::;::~.~:: ~;~;:;~; :;:; ; .;. ::;::::::' ;.;;:; :;:-; .>;:~:;:;:;;;:~;;;:-;:.;:~:;: .:::;:::~. ::;::::::,<
. - .-'.-' - . . -..e DATE (MMIDOt't'tI
09-26-95
THIS CEATlFlCATE IS IBJED AS A MATTER OF INFORMATION ONL V AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CEAT1f1CAT!
DOES NOT AMEND. EXTEND OR ALTER THE COVERAGE AFFORDeD BY
THE POUCIES BELaN.
COMPANIES AFFORDING COVERAGE
ACORD
~
JNaJAm
HAUL TECH ENVIRONMENTAL
7675 W HWY 13 STB 1
SAVAGB, MN 55378
COMPANY
lETTEFI
COMPANY
lETTEFI
COMPANY
lETTER
COMPANY
LETTER
COMPANY
Lm'ER
A
B
C
D
E
OHMS/Mlnnesota Assigned Risk Plan
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE ;:OR"':"HE
POUCV PERIOD INDICATED. NOTWITHSTANDING ANY RECUIREMEHT, TERM OR CONDITION OF AHY CONTRACT OR OTHER DOCUMENT
wrT'H RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFF()R)ED BY THE POUCIES
DESCRIBEO HEREIN IS SUBJECT TO AU. 'THE TERMS, EXCLUSIONS AND CONDmONS OF SUCH POUCIES. UMrrB SHOWN MAY HAVE
BEEN REDUCED BY PAID ClAIMS.
co
.-m
-.-t'!IItl_~
~_IIER
POUCY El'FECTlVE
PCUC'l'DPlRAl1CN
,...... r-.l--~
......... r........."""'1'
uumt
WOA<ER'S COMPENSATlDN
A AIIIJ
EMPl..O'tIAS' l.IA8IUTV
WCA-013784-00
GENENL IoGlIFIEOATW .
PAODtJCT'S.COMPICP *IQ. .
PENONAL .. AtN_ ....,..., .
F..IoCH 0ClaHlENCE .
FIAE 0AIilAGE """ _ ... .
MED~lMr-~ .
~ID"N0U5
UWIT .
IOOILY I~
~..-I .
llOClIl. Y INJURY
~~ .
.......-ERIY OAMAQE .
EACH OCX:UMENCE .
AGQREGAli .
Sf A 1\ITQA'f lJMITI
09-01-95 09-0~-96 EACH ACClCENT . 100,000
CIIU8lE.fIOUCY UMIT . 500,000
CISEASl-EACl1 EM"-OVEI . 100,000
aENBW.1JA8IJTY
CCMMEl'lCIAL OINIML UA8lUTY
aAlMS MADE OCCUR
OWNER'll .. CONlNCTOA'S PROT.
AU1"OMCIII.E UAIIlUTY
Ntf AUTO
ALL OWNID AUTOS
lICttIDA.ID NJTClI
HIAED NJTClI
NON-OWNED AUTCB
GARAGE UA8IJTY
IllCES8 UA8IUlY
uMeflEUA FOIW
0Tl1E" THAN uMlIAELLA ,0Mt
OnEA
DlICNPnON OF 0PEM11CNSII..OCATlON9I\IEHIClESCIAL nne
CORPORATE OFFICERS NOT COVERED BY POLICY
CITY OF PRIOR LAKE
4629 DAKOTA ST
PO BOX 359
PRIOR LAKE. MY 55372
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEl.I.EO
BEFORE THE EXPlRATlON DATE THEREOF, THE ISSUING COMPANY
WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOlDER NAMED TO THE LEFT, BUT FALUAE TO MAIL
SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UAB OF ANY
-. KINO UPON THE COMPANV, IT GE R RE :nv
, AlJ1110AIZED AEPAESENTATNE
~:' '..c>:' ...:.'~' '..:, '.;:.:.~ ," .
.:"" ........
m
-.
BRTIP:CATE OF INSURANCB 09/06/95
J PRODUCER nus CERTIFICATE IS ISStJED AS A HATTER OF INFORMATION ONLY IUro CONFERS
I ALBXANDER &: ALEXANDER IHC. I NO RIGHTS tI'PON THE CERTIFICATE HOLDER. TIUS CERTIFICATE DOES NOT AMEND, 1
I WIRTH PAlUt CENTER I EXTEND OR ALTER THE COVElIAGE AFFORDED BY THE POLICIES BELOW. I
! PO BOX 1360 1- - ---- - ---- _ ---- _ _ -- _ ----- ---- ---- -- -______ __ _ _ 00 ___ __ ___ ___ _ _n ___ _ -- _ _ ---I
I MINNEAPOLIS, MN I I
1 55440-1360 I COMPANIES APFORD:ING COVERAGE I
I PHomi12-520-3000 I I
1-----------------------------------------------------1-----------------------.-------------------------__________________________1
I INSURED I COMPANY LETTER A :INSURANCE CO OF NORTH AMER:ICA I
I 1----------------------------------------------_____________________________1
I I COMPANY LETTER B I
HAUL - TBCH ENVIRONMENTAL 1-- --- -- - --------- - ----- ---- _ --- -- -- -- _ - _ . _ -- _ n --- -- _ -_________ _ _ _ _ _ _ 00____1
767 S WEST HWY. 13 I COMPANY LETTER C I
SA~C;lC, I!!l 1-------------------------------------------------____-----_________________1
55378 I COMPANY LETTER D I
1---------------------------------------------------------------------------1
I COMPANY LETTER E I
> COVERAGES <_.___.__.____e______~._........________.....__..___._--.......--------...---------.....--......___......a..=_~_.....I
nus IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISStlED TO THE INSURED NAMED ABOVE FOR THE POLICY 1
PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY COm'RACT OR OTHER 00ClJMEN'l' wrm RESPECT 1'0 I
WHICH THIS CERTIFICATE MAY BE ISStlED OR MAY PERTAIN, THE INSURNfCE AFFORDED BY THE POLICIES DESCRIBED ItGSIN IS SUBJECT TO I
ALL TERMS. EXCLUSIONS. AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN HAY HAVE BEEN REDUCED BY PMD CLAIMS. I
---------------------------------------------------------------------------------------------------------------------------------1
I COI TYPE OF INSURANCE I POLICY NUMBER I ?OLICY EFF I POLICY UP! ALL LIMITS IN THOUSIUroS \
ILTRI I I DATE I DATE : I
1---1--------------------------------1----------------------------1--------------1----------____1_________ .-----__________________1
I 1 GENERAL LIAB:ILITY I I I I GENERAI. AGGREGATE 11000 1
I I I I I I----____h___________, __n_n_n_J
I AI Jrl COI'f'IERCIAL GEN LIABILITY 1)3344693401 108/30/95/08/30/96 I PRODS-COMP/OPS AGG. 11000 I
I I I I 1---------------------1-----------1
I I [J I J CLAIMS MADE IX OCC. 1 I I PER$. "ADVG. INJURYl1000 I
II I I 1---------------------1-----------1
I I (J OWNER' 5 " CONTRACTORS I I I EACH OCCURRENCE 11000 I
I PROTECTIVE 1 I 1_____________________1_________001
I I I I FIRE DAMAGE 1 I
l : (1 I I I (ANY ONE FIRE I I 50 t
I I I I 1---00-----------00---1-----------1
I I I] , I I MEDICAL EXPENSE I I
I , I I I (ANY ONE PERSONl I 5 I
:---;Ji1iir()!i()!S:I~lC--~~------ ----------------------------:--------------:--------------:-~;~-----------------li-o(jo-----:
I I I I 1---------------------1-----------1
I AI J(J ANY AUTO D3344683401 108/30/95 I 08/30/96 1 SODWl INJtnl.r I I
I I [J ALL OWNED AUTOS I I I (PER PERSON) I I
I 1 (] SCHEDULED At11'OS I I 1--- --- _h -- ---- - -- - --1-- n_ ------1
I I KJ HIRED AUTOS I I I BODILY INJURY I I
I I DC] NON-OWNED AUTOS I I I (PER ACCIDEN'l') I I
I I (J GARAGE LIABILITY I I 1_____________________1___________1
I I [] I I I PROPERTY I I
I I ------------------------- ----------------------------1--------------1--------------1---------------------------------1
I---I-EXCESS LIABILITY I 1 I I EACH oce I AGGREGATE 1
I I [] UMBRELLA FORM I I I I I I
I I (J OTHER THAN ~~~:~_~~~__I----------------------------:-------------_:______________:_______~__________~______________:
1___1__________________ I I I I STATtTrORY I
I I 'fur'ERS ' COMP I I I I EACH ACC I
I I WO_ AND i I I ! DISEASE-POLICY LIMIT I
I I EMPLOYERS' LIAB I I 1 I DISEASE-EACH EMPLOYEE I
I I I I I -------1---------------------------------1
1---1-------------------------------- ---------------------------- -------------- 1------- I 1
I IOTDR I 1 I I I
I I : I I I I
l I ______________________________________________________-----------------.---------------------------------------------i
I-~;~~~;;~~; OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS I
I I
I :
I ______..._________...__...__...___1
1 CANCELLATION <---.--....-...---------.-.
I> CERTIFICATE HOLDER c=~=______.__._._...K___________: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ()- I
I -~"OF THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 3 I
PR:IOR ~....... . PI'RATION DATE ,......... . PT BUT \
I CXTY OF.&.U~ DAYS WRITTEN NOTICE TO THE CERTIFICATE KOLDER. NAMED TOLE .
I BOX 359 . FAILURE TO Mo'IL SUCH NOTICE SHALL IMPO~E N IGAI'IO OR LIABILITY OF \
I 46209RD~i~ ~. . ANY KIND UPON THE COMP____~:_:=~_~~_o__ _ u~: ___n________\
I PRI ---- _ _ -- __n_ -. -- I
I 55372 :-~OR%%= REl>llESENTlO.TIVE ~ I
~CORD 25-8 (3/88)
1_