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Registration Application Page 2 of 2 September 2012 <br />CITY OF LAKE ELMO <br />3880 Laverne Avenue North <br />Lake Elmo, Minnesota 55042 <br />Phone: 651.747.3900 <br /> <br />RIGHT-OF-WAY REGISTRATION APPLICATION <br />INSURANCE (Companies holding franchises with the City need not provide insurance certificates if previously provided.) <br /> Please attach copies of insurance certificates from a company authorized to do business in the State of Minnesota in the following <br />amounts. The City of Lake Elmo shall be listed as additionally insured on insurance certificates. <br />1.GENERAL LIABILITY:Public liability, including premises, products and complete operations. <br />1) Bodily Injury Liability $1,000,000 each person <br />$3,000,000 each occurrence <br />2) Property Damage Liability or $3,000,000 each occurrence <br />3) Bodily Injury and Property $3,000,000 single limit <br />Damage Combined <br />2.COMPREHENSIVE:Automobile Liability Insurance, including owned, non-owned and hired <br />vehicles <br />1) Bodily Injury Liability $1,000,000 each person <br />$3,000,000 each occurrence <br />2) Property Damage Liability or $3,000,000 each occurrence <br />3) Bodily Injury and Property $3,000,000 single limit <br />Damage Combined <br />3.Such Certificate shall verify that the Registrant is insured against claims for personal injury, including death, as well as claims for <br />property damage arising out of (i) use and occupancy of the right-of-way by the registrant, its officers, agents, employees, and <br />permittees, and (ii) placement and use of equipment or facilities in the right-of-way by the registrant, its officers, agents, <br />employees and permittees, including but not limited to, protection against liability arising from completed operations, damage of <br />underground equipment and collapse of property. Such certificate shall also name the City as an additional insured as to whom <br />the coverages required herein are in force and applicable and for whom defense will be provided as to all such coverage. Such <br />certificate shall require that the Director be notified 30 days prior to cancellation of the policy. <br />SIGNATURE OF REGISTRANT <br />By <br />Its <br />Date <br />ACKNOWLEDGEMENT OF INDEMNIFICATION <br />The Applicant hereby acknowledges the indemnification as provided by the applicable section of the City Code. <br />(NOTE: This acknowledgement need not be provided by a company holding a franchise with the City) <br />By <br /> $5,000 SECURITY (ESCROW) VERIFIED Its <br />Date