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DISCLOSURES AND ASSURANCES <br />Statement of Applicant Authority <br />By signing this Statement of Applicant Authority, the <br />undersigned certifies that he or she has authority <br />to represent TKDA as described in Section J under <br />'Required Contents for Proposals' in the Request for <br />Qualifications and Proposals for Engineering Services <br />▪ for the City of Lino Lakes, Minnesota. <br />Nam <br />ia• <br />w <br />WrImo <br />IIMEma <br />William E. Deitner, P.E., CEO <br />Date <br />ACOROa <br />TKDA <br />ENGINEERING • ARCHITECTURE • PLANNING <br />Insurance Coverage <br />TKDA maintains all necessary insurance including <br />General and Automotive Liability with excess umbrella <br />coverage. Workers Compensation, and Professional <br />Liability. <br />CERTIFICATE OF LIABILITY INSURANCE <br />DATE (0MNONTYYI <br />1/25/2011 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: H the certificate holder Is an ADDITIONAL INSURED, the poocy(In) must he endorsed. H SUBROGATION IS WAIVED, subject to <br />the twins and conditions of the policy, certain policies may require en endorsement A statement on this certificate does not corder rights to the <br />cerBBca% holder In lieu or such endorsement/a). <br />PRODUCER <br />B08 Insurance Agency, Inc. <br />245 E Roselawn Ave <br />St. Paul FIN 55117 -1940 <br />M' 555 8088 <br />s„ per 651 288 5137 I .NRr402 810 1500 <br />POLICY NURBER <br />AI a1M 0230931 <br />INSIREg8) AFFORDINGCOYERAGE <br />NAIG8 <br />MIMEO <br />Toltz, Icing, Duvall, Anderson & Associates Inc <br />dba TKDA and Cedar Street Architecture at TKDA <br />Inc dba CSA <br />444 Cedar St Ste 1500 <br />St Paul MN 55101 -2140 <br />POORER A:Charter Oak Fire Ina Co <br />25615 <br />mit..:st_ndard Fire Inc Co <br />19070 <br />..,,continental Casualty Company <br />02128 <br />NE MER D: <br />8 1000000 <br />POURER S; <br />I© COAIMERCIAL GENERALLMERIIY <br />55,F. <br />PROF <br />• <br />V THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />PASSE <br />LTE <br />TYPE OF INSURANCE <br />OPOLICY <br />POLICY NURBER <br />EFF <br />IMMS008'YYYI <br />POLICY EXP <br />twormlYYYYI <br />urns <br />GENERAL LIABILITY <br />EACH OCCURRENCE <br />8 1000000 <br />I© COAIMERCIAL GENERALLMERIIY <br />RENTED <br />PEEWEES (Ea ocaarandl <br />6 50000 <br />A <br />IIIIII M 0.80 SMAOE © OCCUR <br />P6307328N852C0610 <br />8/28/2010 <br />8/28/2011 <br />iD (A,R,ar,...) <br />1 5000 <br />■ <br />PERSONAL 8 ADV INJURY <br />0 1000000 <br />■ <br />GENERAL AGGREGATE <br />S 1000000 <br />GENE AGGREGATE WAR AP�PLIE S PER <br />PROCTS- COMROP AGG <br />DU <br />$ 1000000 <br />8 <br />X POLICY I-1 I j LOC <br />AUTOMOBILE LUealrr <br />QED SINGLE 1.805 <br />8 1000000 <br />X ANY AUTO <br />/2011 <br />BODILY INJURY (Par Eamon) <br />1 <br />B <br />ALL ONT ®AUTOS <br />10131073211911152211.10 <br />0/28/2010 <br />8/20 <br />BODILY INJURY (Per a0CideN) <br />8 <br />SCHEDULED AUTOS <br />PROPERTY DAMAGE <br />S <br />■ HIRED AUTOS <br />(Pm .0dd58) <br />III, NonowN1005101 <br />Uninsured ARRAN Opnip1ne° <br />0 <br />PIP-135119 <br />8 <br />urweu.0 LIAR X occuR <br />EACH OCCURRENCE <br />8 1000000 <br />© 800E88 UAB CLAwg.MADE <br />AGGREGATE <br />0 1000000 <br />III DEDUCTIBLE <br />6 <br />8 <br />B <br />X LION 8 0 <br />PCOP732BN85251510 <br />8/2E /2010 <br />8/20/2011 <br />B <br />080000 COl8ISATON <br />x 1ITCLMRI I EAR <br />AIM EMPLOYER*. weary YIN <br />511( PROPRIETCPPPARTNERACAECUTIVE <br />El EACH ACCIDENT <br />8 100000 <br />© <br />OFFyNaaaletlatwRF�belal <br />NIA <br />PC0e7328N85210 <br />0/28/2010 <br />8/28/2011 <br />El01SE -EA EMFl0100 <br />0 100000 <br />DE PfAN OF OPERATIONS Now <br />EL DISEASE- POl1CY LIMIT <br />8 500000 <br />C <br />PROFESSIOAL LIAR INCI. <br />0m00821.2804 <br />0/20/2010 <br />0/28/2011 <br />EACH CUM 1000000 <br />POLLOTIOB/ RETRO 8/28/61 <br />MR110 WIDE <br />ANNUAL AGGREGATE 1000000 <br />DESCRIPTION OF OPERAT NR / LOCATIONS I Y9OCLES URN. ACORD 191, AG®m W RaRurlas ad,. W M. Emma yes M lumen) <br />City of Lino Lakes 1 City Engineering Services 21 <br />