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• AMERICAN HARDWARE MUTUAL INSURANCE COMPANY • • HOME OFFICE-MINNEAPOLIS.MINNESOTA CENTRAL DIVISION CITY OF ST. ANTHOIIY �p P.O.BOX 455 MINNEAPOLIS,MINNESOTA 55040 3301 Silver Lake Road MEMORANDUM OF INSURANCE Minneapolis. Minnesota To CITY OF ST ANTHONY. ADMINIfTRATIVE OFFICES Address 33Q1-5.1-MR-ij,AU-81D. MI.NNEANUS, MN 55418 Name of Insured COUNTRY QIIR MAMETS INC Address 3000 FRANCE AME_50_tUNNEAP_01.15 MN 55416_ Project i Directions: Please complete in duplicate with typewriter or by printing in ink. Location 150 APACHE PL_AZAT37IN-ME-NE.& SILVER LAKE RD This is to certify that the following policies,subject to their,tents,conditions and exclusions,have been issued. i Date: ..�T lY�)1ty &4 TYPE OF OF POLICY: Scheduled Non-Comprehensive Auto Liability ❑ Comprehensive Auto Liability ❑ True Name: (Last, First. Middle) Scheduled Non-Comprehensive General Liability ❑ i Comprehensive General Liability ❑ " Other than above_SPFSI_AI MIILTI_PFRIL ❑9 . Residence Address: (Number, Street. City, State) 3. Phone Number- Policy No. 0-2291061 Inception Date 04`01-80 Expiration Date 04-01-83 7 ✓ &n — 7 �y'O -7 4. Business Address: (Number, Stftet. city, State) 5. Phone Number: Limit of Liability: Automobile Other Than Automobile ' 9aa - 933 Bodily Injury Liability Each Person ! 6. Place of Birth: (County, City, State Date of Birth: (MO./Day/Yr.) Each Occurrence Aggregate Property Damage Liability Each Occurrence , U. S. Citizen? Y s Naturalize ? Yes It Yes, give date and place. Aggregate , Bodily Injury&Property 500.000 Each Occurrence No No Damage Liability 500,000 Aggregate 9. If you have ever used or beer. know by a name or names other than the true name Coverage Provided: Yes No given in 11 above, list such name(s) and information concerning dates and places Premisesor Lessor'siiskonly EX ❑ where used. Operalions0f Contractor LX ❑ operat ions of Subcontr;ICtol lcominge,tl EX@ ❑ Names Dates, Places, and Circumstances Products-Completed Ope anions Ex ❑ Contractual Liability 10 include Coverage for'hold Kann Loss agreement," if such agreenem is contained in the specifications of subcontract. CX ❑ Property damage liability covers: Damage due to blasting Ex ❑ Damage due to collapse EJ [] Damage to underground facilities - Ex ❑ Broad Form coverage EX ❑ Other than above 1 IDIIOR I JAR-L1Ml.T_50Q,000— Ex ❑, W011KER'S COMPENSATION: Policy No. 3-2150423 - Inception Date 01-01-83 Expiration Date 01-01-84 Coverage-Worker's Compensation,Statutory Employer's Liability Limit S 100,000 10. Marital Status: Single Widowed Separated UMBRELLA LIABILITY: Policy No. 2-2 14 7361 Inception Date 04'01-52— Expiration Date M-0i-83 Married Divorced LIMITS OF ?' LIABILITY Is 15,000,000 Each Occurrence Is 10,000 Retained limit IS 15,000,000 Aggregate limit 1. If Married, true name, place anti date of birth, and residence adJress of spouse: t. ' place In the event or any material Chan - s c True Nam ve.n,suspension or ancclatian or any of me alcove paicies. 10 DAYS %1• e: notice+hereol will be mailed o the parties to whom this memorandum is issued. THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS,EXTENDS OR ALTERS THE ��;/ Place and Date of 9Lrtfi: COVERAGE AFFORDED BY THE POLICY OR POLICIES TO WHICH IT PERTAINS. p;i + Residence Address: ry 3 jQ yam, �/Jj. -5533/ Dated 02-23-83 S 1 By Authorized Insurance Company Rep, en able d 511-1592(11-79) y