Trade License Application Form (Guidelines And Checklist) (Page 4 of 4) in pdf

City of Minneapolis

Requirements for Insurance Certificates

CERTIFICATE OF LIABILITY INSURANCE

PRODUCER

Agency

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS

Certificate cannot be pending,

Address

NO RIGHTS UPON THE CERTIFICATE HOLDER.

binder or TBA.

City, State, Zip

THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE

AFFORDED BY THE POLICIES BELOW.

INSURERS AFFORDING COVERAGE

The Legal/Corporate Name

INSURED

INSURER A:

must match exactly

INSURER B:

(word for word) to the

INSURER C:

Approved Licensee Name

(including Inc, or LLC),

INSURER D:

Trade Name (DBA)

INSURER E:

and address of premises.

COVERAGES

THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.

NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS

CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,

EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

POLICY

EFFECTIVE

POLICY

INSR

NUMBER

DATE

EXPIRATION

LTR

TYPE OF INSURANCE

(MM/DD/YY)

DATE (MM/DD/YY)

LIMITS

GENERAL LIABILITY

EACH OCCURRENCE

† COMMERCIAL GENERAL LIABILITY

FIRE DAMAGE (Any

one fire)

† CLAIMS MADE

MED EXP

† OCCUR

(Any one person)

†

PERSONAL & ADV

INJURY

†

GENERAL

AGGREGATE

GEN’L AGGREGATE LIMIT APPLIES PER:

PRODUCTS –

COMP/OP AGG

† POLICY

† PROJECT

† LOC

AUTOMOBILE LIABILITY

COMBINED

† ANY AUTO

SINGLE LIMIT

(Ea accident)

† ALL OWNED AUTOS

BODILY INJURY

† SCHEDULED AUTOS

(Per person)

† HIRED AUTOS

BODILY INJURY

† NON – OWNED AUTOS

(Per accident)

†

PROPERTY DAMAGE

(Per accident)

†

AUTO ONLY – (Ea

GARAGE LIABILITY

Accident)

OTHER

† ANY AUTO

THAN

ACC

AUTO

†

ONLY:

AGG

EXCESS LIABILITY

EACH OCCURRENCE

† OCCUR † CLAIMS MADE

AGGREGATE

† DEDUCTIBLE

† RETENTION

WORKER’S COMPENSATION AND EM

X/WC STATUTORY

PLOYER’S LIABILITY

LIMITS / OTHER

E.L. EACH

ACCIDENT

E.L. DISEASE – EA

EMPLOYEE

E.L. DISEASE –

POLICY LIMIT

OTHER

DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS:

ADDITIONAL INSURED; INSURER LETTER

CERTIFICATE HOLDER

City of Minneapolis

Licenses and Consumer Services

AUTHORIZED REPRESENTATIVE

1-C City Hall

Original signature or

350 South 5th Street

stamp of Agent.

Minneapolis, MN 55415

Applications will be returned if requirements are not complete.

This application must be stapled and all pages attached to avoid processing delays. Page 4 of 4 - October 2015

Trade License Application Form (Guidelines And Checklist) Page 4

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