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<br />
<br />ONLY
<br />LTER 7
<br />This is to Certify that
<br />Eugene Sand Construction, Inc.
<br />PO Box 1067
<br />Eugene, OR 97440
<br />Liberty
<br />Mutual.
<br />is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the listed policy(ies) is subject to all their terms, exclusions and
<br />If the eertiacata mtpaalion date is oontiauoua or aumded farm, }ou will be notified if wvacage is termlaated ar reduced tJetom fire eeRificxte expiration data
<br />SPECIAL NOTIC&OftIO: ANY PERSON WHO. WfrH INTENT TO DEFRAUD ORRNOWINO THAT HE IS FACILrrATINO A FRAUD AGAINST AN INSURER, SUBMITS
<br />AN APPLICATION OR PILES A CLAIM CONTAINING A FALSE OR DECEPTIVB STATEMENT IS GUILTY OF INSURANCE FRAUD.
<br />IMPORTANT NOTICR TO FLORIDA POL[CYHO[.DER.SRND CERTIFICATE HOLD&R3: IN THE EVENT YOU HAV E ANY QUESTIONS OR NEED RJFORMATION ABOUT
<br />THIS CERTIFICATE FOR ANY REASON. PLEASE CONTACT YOUR LOCAL SALES PRODUCER WHOSE NAME AND TELEPB:ONB NUMBER APPEARS IN Tt~ LOWER
<br />RIGE17 HAND CORNER OF TIQS CF.RTIF/CAT& THE APPROPRIATE LOCAL SALES OFFICE MAD.IIJO ADDRESS MAY ALSO BE OBTAB7ED BY CALLING THIS NUMBER. Liberty Mutual
<br />Insurance Group
<br />NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS ENTERED BELOW.)
<br />BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT CANCEL OR REDUCE THE
<br />INSURANCE AFFORDED UNDER THE ABOVE POLICIES UNTIL AT LEAST 30 DAYS NOTICE
<br />OF SUCH CANCELLATION HAS BEEN MAILED TO:
<br />t:omm~ons ane rs no[ atmree o an re uuemenr, tarot or comm~ oa or an contract or uwe, uucu,ucm w,., , ,~ . w w,,,~.. ,,,,~ ~~,,,.,,:a,~ ,,,,
<br /> EXP DATE
<br /> ^ CONTRJUOUS
<br />TYPE OF POLICY ~ EXTENDED POLICY NUMBER LIMIT OF LIABILITY
<br /> (~ POLICY TERM
<br />WORKERS 9/1/2009 WA7-C8D-004095-028 COVERAGEAFFORDEDUNDER
<br />WC LAW OF THE FOLLOWING
<br />EMPLOYERS LIABILITY
<br /> WC7-C85-004095-018 STATES:
<br />COMPENSATION B
<br />dil
<br />l
<br />b
<br />A
<br />id
<br />t
<br /> ALL STATES EXCLUDING en
<br />o
<br />y
<br />njury
<br />y
<br />cc
<br /> MONPOLISTICS STATES AND $1,000,000 Each Accidem
<br /> NY Bodily Injury by Disease
<br /> OR
<br />WI $1,000,000 Policy Limit
<br /> , Bodily Iq jury by Disease
<br /> $1,000,000 Each Person
<br /> General Aggregate - Other than Products /Completed Operations
<br />GENERAL LIABILITY 9/1/2009 'TB2-C85-004095-118 $2,000,000
<br />(~ OCCURRENCE Products /Completed Operations Aggregate
<br /> $2,000,000
<br />^ CLAIMS MADE Bodily Injury and Property Damage Liability
<br /> $2,000,000 PerOxmnence
<br /> RETRO DATE Personal Injury
<br /> Ineiuded* Per Persoa /Organization
<br /> Other Older
<br /> Included in BI/PD Liability FIRE DAMAGE $100,000;PER
<br /> PROJECT AGGREGATE
<br />AUTOMOBILE 9/1 /2009 AS2-C85-004095-128 $2,000,000 B ~d P °t~~ am't
<br />LIABILITY
<br /> Each Person
<br />
<br />m`pWNED
<br /> Each Accident of Occurrence
<br />D NON-OWNED
<br />
<br />Q HIRED Each Accident or Occurrence
<br />OTHER
<br />9/1 /2009 Auto: Comp Ded $10,000/Coil Ded $10,000
<br />Evidence of coverage
<br />ADDITIONAL COMMENTS
<br />Certificate Holder is named as addittonal insured with respect to Protect PPP08 -Roosevelt Blvd. -Job #4479. This insurance is primary and non-
<br />contributory. Includes waiver of subrogation. Per project aggregate applies.
<br />NAME AND
<br />ADDRESS
<br />OF INSURED
<br />THIS CERTIFICATE IS NOT AN
<br />City of Eugene ~ ~ ~%~
<br />244 E. Broadway Judith Balazentls
<br />Eugene, OR 97401 Pittsburgh / 0387 AUTHORIZED REPRESINTATIVE
<br />x ~ ~ 12 Federal Street, Ste. 310
<br />pJJtsburoh PA 15212-5706 412-231-1331 9/9/08
<br />OFFICE PHONE DATE ISSUED
<br />This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by those Companies 1VM 772
<br />
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