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Certificate of Insurance <br /> THIS CERTIFICATE ISSUED AS A MATTER OF INFORMATION. ONLY AND CONFERS NO RIGHT UPON YOU THE CERTIFICATE HOLDER. THIS CERTIFICATE IS NOT AN <br /> INSURANCE POLICY AND DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW <br /> This is to Certify that <br /> I Egge Sand & Gravel • <br /> CPM Develo ment Cor oration dba ~ NAME AND <br /> p p ADDRESS Libe <br /> 90520 Coburg Rd. ~ <br /> Eugene, OR 97408 ~ OF INSURED 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, <br />exclusions and <br /> Conditions and is not altered b an re uirement, term or condition of an contract or outer document with res ect to which this certificate ma be issued. <br /> EXP DATE <br /> ? coNTlNUOVs <br /> TYPE OF POLICY ? EXTENDED POLICY NUMBER LIMIT OF LIABILITY <br /> Q POLICY TERM <br /> WA7-C8D-004095-028 COVERAGE AFFORDED UNDER <br /> WORKERS 9/1/2009 WC7-C85-004095-018 WC LAW OF THE FOLLOWING EMPLOYERS LIABILITY <br /> COMPENSATION sTATES: - <br /> ALL STATES EXCLUDING Bodily Injury by Accident <br /> MONPOLISTICSSTATESAND $1,000,OOOEachAccident <br /> NY Bodily Injury by Disease <br /> OR, WI $1+000,000 Policytimit <br /> Bodily Injury by Disease _ <br /> $1,000,000 Each Person <br /> General Aggregate -Other than Products /Completed Operations <br /> GENERAL LIABILITY 9/1/2009 T62-C85-004095-118 $2,000,000 <br /> ICJ OCCURRENCE Products /Completed Operations Aggregate <br /> $2,000,000 <br /> ? CLAIMS MADE Bodily Injury and Property Damage Liability <br /> <br /> ' $2,000,000 PerOccutrence <br /> RETRO DATE Personal Injury <br /> Ineluded* Per Person/Organization <br /> Other Other <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 g L And <br /> P.D.tComb nedmit <br /> LIABILITY <br /> Q OWNED Each Person <br /> Each Accident or Occurrence <br /> D NON-OWNED <br /> Q HIRED Each Accident or Occurrence <br /> OTHER <br /> 9/1/2009 Auto: Comp Ded $10,000/Colt Ded $10,000 <br /> Evidence of coverage <br /> ADDITIONAL COMMENTS <br /> Certificate Holder is named as additional insured with respect to 2009 Pothole. Repair -.Job #4624 project. This insurance is primary and non- <br /> e contributory. Includes Waiver of Subrogation. Per project aggregate applies. <br /> ' If the certificate expiration date is continuous or extended term, you will be notified if coverage is terminated or reduced before the certificate expiration data <br /> SPECIAL NOTICE-OHIO: ANY PERSON WFiO, W[TI{ INTENT TO DEFRAUD OR KNOWING THAT HIi IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS <br /> AN APPLICATION OR FILES A CLAIM CONTAINRJG A FALSE OR DECEPTIVE STATEIvIENT iS GUILTY OF INSURANCE FRAUD. <br /> IMPORTANT NOTICE TO FLORH)A POLICYHOLDERS AND CERTIFICATE HOLDERS: M THE EVEN7 YOU HAVE ANY QUESTIONS OR NEED INFORMATION ABOUT <br /> THIS CERTIFICATE FOR ANY REASON, PLEASE CONTACT YOIAL LOCAL SALES PRODUCER WHOSE NAME AND TELEPHONE NUMBER APPEARS IN THE LOWER <br /> RIGHT HAND CORNER OF THIS CERTIFICATE. THE APPROPRIATE LOCAL SALES OFFICE MAILING ADDRESS MAY ALSO BE OBTAINED BY CALLING THIS NUMBER. Liberty MUtUaI <br /> Insurance Group <br /> NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS ENTERED BELOW.). <br /> BEFORE THE STATED EXPQtATION 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 /> City of Eugene ~ <br /> 99 E. Broadway, Suite 400 ~ <br /> Eugene, OR 97401 Pittsburgh / 0387 AUTHORIZEDaREPRESENTATIVE <br /> ~ ~ ~ I 12 FederaFStreet, Ste. 310 <br /> J Pittsburgh PA 15212-5706 412-231-1331 6/16/09 <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 NM 772 <br /> <br />