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Certificate of Insurance
ACG'RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 12/18/2020 THIS TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT Calll Roth PRODUCER NAME: Assurance Partners,LLC PHONE (800)563-1871 FAX NO): (785)825-5098 (AIC,No,Ext): 201 E Iron Avenue ADDRESS: croth@yourassurance.com P.O.Box 1213 INSURER(S)AFFORDING COVERAGE NAIC a Salina KS 67402-1213 INSURERA: Union Insurance Company 25844 INSURED INSURER B: Kansas Builders'Insurance Group 0010 Lancaster Construction,Inc. INSURER C: 618 Francis Ave INSURER D: INSURER E: Salina KS 67401-2448 INSURER F: COVERAGES CERTIFICATE NUMBER: 20.21 PKG/21.22 WC REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/OD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000 DAMAGE TO REN IED 300,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10'000 A CPA3210798-22 12/28/2020 12/28/2021 PERSONAL&ADV INJURY $ 1,000,000 / GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: / PRO- PRODUCTS-COMP/OP AGO $ 2,000,000 POLICY X JECT LOC $ OTHER: COMBINED SINGLE LIMIT $ 1,000,000 AUTOMOBILE LIABILITY (Ea accident) _ X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED CPA3210798-22 12/28/2020 12/28/2021 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOSPROPERTY DAMAGE HIRED NON-OWNED (Per accident) $ X AUTOS ONLY X AUTOS ONLY $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1'000'000 A EXCESSLIAB - CPA3210798-22 12/28/2020 12/28/2021 AGGREGATE $ 1,000,000 CLAIMS-MADE $ DED RETENTION$ _ WORKERS COMPENSATION X STATUTE ETH AND EMPLOYERS'LIABILITY Y I N1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE NIA 20211191 01/01/2021 01/01/2022 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBH) EXCLUDED. E.L.DISEASE-EA EMPLOYEE $ (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Project No.90032 10th and Elm Parking Lot CLCA2093,CLCG0492 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Salina 300 W.Ash AUTHORIZED REPRESENTATIVE lnn/�/q Salina KS 67401 (/y OP // ©1988-20155 ACC ORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CL CG 04 92 10 18 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL LIABILITY ULTRA PLUS ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SUMMARY OF COVERAGE EXTENSIONS Provision Name Of Coverage Extension Included or Limit of Insurance A. Miscellaneous Additional Insureds Included B. Expected Or Intended Injury Or Damage Included C. Knowledge Of Occurrence Included D. Legal Liability—Damage To Premises Rented To You (Fire, Lightning, $300,000 Explosion, Smoke, Or Leakage From Automatic Fire Protective Systems) E. Medical Payments See Declarations F. Mobile Equipment Redefined Included G. Newly Formed Or Acquired Organization, Partnership Or Limited Liability Included Company And Extended Period Of Coverage H. Who Is An Insured—Amendment Included 1. Non-Owned Watercraft(Increased to maximum length of less than 51 Included feet) J. Supplementary Payments—Increased Limits 1. Bail Bonds $3,000 2. Loss Of Earnings $ 1,000 K. Unintentional Omission Or Unintentional Error In Disclosure Included L. Waiver Of Transfer Of Rights Of Recovery Against Others Included M. Liberalization Clause Included N. Incidental Medical Malpractice Included The above is a summary only. Please consult the specific provisions that follow for complete information on the extensions provided. The provisions of the Commercial General Liability in writing in a contract or agreement that such Coverage Part apply except as otherwise provided in person or organization be added as an this endorsement. This endorsement applies only if additional insured on your policy, provided such Coverage Part is included in this policy. that: A. MISCELLANEOUS ADDITIONAL INSUREDS a. The written contract or written agreement is: 1. Section II —Who Is An Insured is amended (1) Currently in effect or becoming to include as an insured any person or effective during the term of this policy; organization (referred to as an additional and insured below) described in Paragraphs A.1.c.(1) through A.1.c.(9) below when you (2) Fully executed by you and the and such person or organization have agreed additional insured prior to the "bodily CL CG 04 92 10 18 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 8 with its permission injury", "property damage" or (1.1) The preparing, approving, "personal and advertising injury". or failing to prepare or approve, maps, shop b. The insurance afforded by this provision drawings, opinions, reports, does not apply to any person or surveys, field orders, organization included as an additional change orders or drawings insured by a separate endorsement and specifications; or issued by us and made a part of this policy or coverage part. (1.2) Supervisory, inspection, architectural or engineering c. Only the following persons or activities. organizations are additional insureds under this provision, with coverage for This exclusion applies even if the such additional insureds limited as claims against any insured allege provided herein: negligence or other wrongdoing in the supervision, hiring, employment, (1) Persons or Organizations For training or monitoring of others by that Whom Operations Are Performed insured, if the "occurrence" which (a) Any person or organization for caused the"bodily injury"or"property whom you are performing damage", or the offense which operations when you and such caused the "personal and advertising person or organization have injury", involved the rendering of, or agreed in writing in a contract or the failure to render, any professional agreement that such person or architectural, engineering or organization be added as an surveying services. additional insured to your policy; (ii) "Bodily injury" or "property and damage"occurring after: (b) Any other person or organization (1.1) All work, including you are required to add as an materials, parts or additional insured under the equipment furnished in contract or agreement described connection with such in paragraph (a)above. work, on the project (c) Such person(s)or organization(s) (other than service, is an additional insured only with maintenance or repairs) respect to liability for "bodily to be performed by or on injury", "property damage" or behalf of the additional "personal and advertising injury" insured(s) at the location caused, in whole or in part, by: of the covered operations has been completed; or (I) Your acts or omissions; or (1.2) That portion of "your (II) The acts or omissions of work" out of which the those acting on your behalf; injury or damage arises in the performance of your ongoing has been put to its operations for the additional insured. intended use by any person or organization (d) With respect to the insurance other than another afforded to these additional contractor or insureds, the following additional subcontractor engaged in exclusions apply: performing operations for This insurance does not apply to: a principal as a part of the same project. (I) "Bodily injury", "property damage" or "personal and (2) Managers Or Lessors Of Premises advertising injury" arising out A manager or lessor of premises but of the rendering of, or the only with respect to liability arising out failure to render, any of the ownership, maintenance or use professional architectural, of that part of the premises leased to engineering or surveying services, including: CL CG 04 92 1018 Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 8 with its permission you and subject to the following contract or written agreement with additional exclusions: you for such leased equipment ends. This insurance does not apply to: This insurance does not apply to any (a) Any "occurrence" which takes "occurrence" which takes place after place after you cease to be a the equipment lease expires. tenant in that premises. (6) State, Municipality, Governmental (b) Structural alterations, new Agency Or Subdivision Or Other construction or demolition Political Subdivision — Permits Or operations performed by or on Authorizations Relating To behalf of such additional insured. Premises (3) Mortgagee,Assignee Or Receiver Any state, municipality, governmental agency or subdivision or other A mortgagee, assignee, or receiver political subdivision subject to the but only with respect to their liability following additional provisions: as mortgagee, assignee, or receiver (a) This insurance applies only with and arising out of the ownership, respect to: maintenance, or use of a covered premises by you. (i) The following hazards for This insurance does not apply to which the state, municipality, structural alterations, new governmental agency or construction or demolition operations subdivision or other political performed by or on behalf of such subdivision has issued a additional insured. permit or authorization in connection with premises you (4) Owners Or Other interests From own, rent or control and to Whom Land Has Been Leased which this insurance applies: An owner or other interest from whom (1.1) The existence, land has been leased to you but only maintenance, repair, with respect to liability arising out of construction, erection the ownership, maintenance or use of or removal of that part of the land leased to you and advertising signs, subject to the following additional awnings, canopies, exclusions: cellar entrances, coal holes, driveways, This insurance does not apply to: manholes, marquees, (a) Any "occurrence" which takes hoist away openings, place after you cease to lease sidewalk vaults, street that land. banners or decorations and similar exposures; (b) Structural alterations, new or construction or demolition operations performed by or on (1.2) The construction, behalf of such additional insured. erection or removal of (5) Lessor Of Leased Equipment elevators; or (1.3) The ownership, Any person(s)or organization(s)from maintenance or use of whom you lease equipment but only with respect to liability for "bodily any elevators covered injury", "property damage" or by this insurance. "personal and advertising injury" (ii) Operations performed by you caused, in whole or in part, by your or on your behalf for which maintenance, operation or use of the state, municipality, equipment leased to you by such governmental agency or person(s)or organization(s). subdivision or other political A person's or organization's status as subdivision has issued a an additional insured under this permit or authorization. endorsement ends when their written CL CG 04 92 10 18 Includes copyrighted material of Insurance Services Office, Inc., Page 3 of 8 with its permission (b) This insurance does not apply to (Iii)Any physical or chemical "bodily injury", "property damage" change in the product made or "personal and advertising intentionally by the injury" arising out of operations vendor; performed for the state, (Iv) Repackaging, except when municipality, governmental unpacked solely for the agency or subdivision or other purpose of inspection, political subdivision. demonstration, testing, or the (7) Controlling Interest substitution of parts under instructions from the Any person(s) or organization(s) with manufacturer, and then a controlling interest in the Named repackaged in the original Insured but only with respect to their container; liability arising out of: (v) Any failure to make such (a)Their financial control of you; or inspections, adjustments, (b) Premises they own, maintain or tests or servicing as the control while you lease or occupy vendor has agreed to make these premises. or normally undertakes to make in the usual course of This insurance does not apply to business, in connection with structural alterations, new the distribution or sale of the construction or demolition operations products; performed by or for such person(s)or organization(s). (v1) Demonstration, installation, servicing or repair (8) Co-Owner Of Insured Premises operations, except such A co-owner of a premises co-owned operations performed at the by you and covered under this vendor's premises in insurance but only with respect to the connection with the sale of co-owner's liability as co-owner of the product; such premises. (vii) Products which, after (9) Vendors distribution or sale by you, have been labeled or (a) Any person(s) or organization(s) relabeled or used as a (referred to as vendor), but only container, part or ingredient with respect to "bodily injury" or of any other thing or "property damage" arising out of substance by or for the "your products" which are vendor; or distributed or sold in the regular course of the vendor's business. (vIII)"Bodily injury" or "property damage" arising out of the The insurance afforded the sole negligence of the vendor vendor does not apply to: for its own acts or omissions (I) "Bodily injury" or "property or those of its employees or damage" for which the anyone else acting on its vendor is obligated to pay behalf. However, this damages by reason of the exclusion does not apply to: assumption of liability in a (1.1) The exceptions written contract or written contained in Sub- agreement. This exclusion paragraphs (Iv) or does not apply to liability for (vi); or damages that the vendor would have in the absence of (1.2) Such inspections, the written contract or written adjustments, tests or agreement; servicing as the vendor has agreed to (Ii) Any express warranty make or normally unauthorized by you; undertakes to make I CL CG 04 92 10 18 Includes copyrighted material of Insurance Services Office, Inc., Page 4 of 8 with its permission in the usual course of B. EXPECTED OR INTENDED INJURY OR business, in DAMAGE connection with the Exclusion 2.a. Expected Or Intended Injury of distribution or sale of Section I — Coverage A — Bodily Injury And the products. Property Damage Liability is deleted and (b) This insurance does not replaced by the following: apply to any insured person a. Expected Or Intended Injury Or Damage or organization, from whom you have acquired products, "Bodily injury"or"property damage"expected or any ingredient, part or or intended from the standpoint of the insured. container, entering into, This exclusion does not apply to"bodily injury" accompanying or containing or"property damage"resulting from the use of such products. reasonable force to protect persons or 2. With respect to coverage provided by this property. Provision A. Miscellaneous Additional C. KNOWLEDGE OF OCCURRENCE Insureds, the following additional provisions Paragraph 2.a. Duties In The Event Of apply: Occurrence, Offense, Claim Or Suit of Section a. Any insurance provided to an additional IV — Commercial General Liability Conditions insured designated under Paragraphs is deleted and replaced by the following: A.1.c.(1) through A.1.c.(8) above does a. You must see to it that we are notified as soon not apply: as practicable of an "occurrence" or an (1) To "bodily injury" or "property offense which may result in a claim only when damage" included within the the "occurrence"or offense is known to: "products-completed operations ( ) You, if 1you are an individual; hazard"; or (2) To "bodily injury", "property damage" (2) A partner, if you are a partnership; or "personal and advertising injury" (3) A manager, if you are a limited liability arising out of the sole negligence of company; or such additional insured. (4) An "executive officer" or the "employee" b. The insurance afforded to such additional designated by you to give such notice, if insured only applies to the extent you are an organization other than a permitted by law. partnership or a limited liability company. c. The insurance afforded to such additional To the extent possible, notice should include: insured will not be broader than that which you are required to provide by the written (i) How,when and where the"occurrence"or contract or written agreement. offense took place; 3. With respect to the insurance afforded to the (II) The names and addresses of any injured additional insureds within this Provision A. persons and witnesses; and Miscellaneous Additional Insureds, the (Iii) The nature and location of any injury or following is added to Section III — Limits Of damage arising out of the"occurrence"or Insurance: offense. The most we will pay on behalf of the D. LEGAL LIABILITY — DAMAGE TO PREMISES additional insured is the amount of insurance: RENTED TO YOU (Fire, Lightning, Explosion, a. Required by the written contract or written Smoke, Or Leakage From Automatic Fire agreement; or Protective Systems) b. Available under the applicable Limits Of If damage to premises rented to you is not Insurance shown in the Declarations; otherwise excluded from this policy or coverage part, then the following provisions apply: whichever is less. 1. Under Section I — Coverage A — Bodily This endorsement shall not increase the Injury And Property Damage Liability, the applicable Limits Of Insurance shown in the last paragraph(after the exclusions)is deleted Declarations. and replaced by the following: CL CG 04 92 10 18 Includes copyrighted material of Insurance Services Office, Inc., Page 5 of 8 with its permission Exclusions c. through n. do not apply to you or temporarily occupied by you with damage by fire, lightning, explosion, "smoke", permission of the owner; or leakage from automatic fire protective 5. Subparagraph a. of Definition 9. "Insured systems to premises while rented to you or contract" of Section V — Definitions is temporarily occupied by you with the deleted and replaced by the following: permission of the owner. A separate limit of insurance applies to this coverage as a. A contract for a lease of premises. described in Section III — Limits Of However, that portion of the contract for a insurance. lease of premises that indemnifies any person or organization for damage by fire, 2. The paragraph immediately after Sub- lightning, explosion, "smoke" or leakage paragraph j.(6)of Paragraph 2.Exclusions of from automatic fire protective systems to Section I—Coverage A—Bodily Injury And premises while rented to you or Property Damage Liability is deleted and temporarily occupied by you with replaced by the following: permission of the owner is not an"insured Paragraphs (1), (3) and (4) of this exclusion contract". do not apply to"property damage" (other than 6. As used in this Provision D. Legal Liability— damage by fire, lightning, explosion, "smoke", Damage To Premises Rented To You: or leakage from automatic fire protective systems) to premises, including the contents "Smoke" does not include smoke from of such premises, rented to you for a period of agricultural smudging, industrial operations or seven or fewer consecutive days. A separate "hostile fire". limit of insurance applies to Damage To E. MEDICAL PAYMENTS Premises Rented To You as described in Section III—Limits Of Insurance. The Medical Expense Limit is changed, subject to the terms of Section III—Limits Of Insurance,to 3. Paragraph 6. of Section III — Limits Of the Medical Expense Limit shown in the Insurance is deleted and replaced by the Declarations. following: 6. Subject to Paragraph 5. above, the F. MOBILE EQUIPMENT REDEFINED greater of: Subparagraph f.(1) of Definition 12. "Mobile a. $300,000; or equipment" of Section V—Definitions is deleted and replaced by the following: b. The Damage To Premises Rented To (1) Equipment with a gross vehicle weight of You Limit shown in the Declarations, 1,000 pounds or more and designed primarily is the most we will pay under Coverage A for: for damages because of "property (a) Snow removal; damage"to premises while rented to you, or in the case of damage by fire, lightning, (b) Road maintenance, but not construction explosion, "smoke", or leakage from or resurfacing; or automatic fire protective systems, while (c) Street cleaning; rented to you or temporarily occupied by you with permission of the owner. G. NEWLY FORMED OR ACQUIRED This limit will apply to all damage ORGANIZATION, PARTNERSHIP OR LIMITED proximately caused by the same event, LIABILITY COMPANY AND EXTENDED whether such damage results from fire, PERIOD OF COVERAGE lightning, explosion, "smoke", leakage Paragraph 3. of Section II—Who is An Insured from automatic fire protective systems, or is deleted and replaced by the following: other covered causes of loss or any 3. Any organization you newly acquire or form, combination thereof. other than a joint venture, and over which you 4. Subparagraph b.(1)(a)(1I) of Paragraph 4. maintain ownership or: Other Insurance of Section IV — a. Majority interest of more than 50% if you Commercial General Liability Conditions isare a corporation; deleted and replaced by the following: (II) That is fire, lightning, explosion, "smoke" b. Majority interest of more than 50% as a general partner of a newly acquired or or leakage from automatic fire protective formed partnership; and/or systems insurance for premises rented to CL CG 04 92 10 18 Includes copyrighted material of Insurance Services Office, Inc., Page 6 of 8 with its permission c. Majority interest of more than 50% as an c. Past partnership, joint venture or limited owner of a newly acquired or formed liability company; limited liability company; that is not shown as a Named Insured in the will qualify as a Named Insured if there is no Declarations. other similar insurance available to that I. NON-OWNED WATERCRAFT organization. However, for these organizations: Subparagraph (2) of Exclusion 2.g. Aircraft, (I) Coverage under this provision is afforded Auto Or Watercraft of Section I—Coverage A— only until the next anniversary date of this Bodily injury And Property Damage Liability is policy's effective date after you acquire or deleted and replaced by the following: form the organization, partnership or (2) A watercraft you do not own that is: limited liability company, or the end of the (a) Less than 51 feet long; and policy period, whichever is earlier; (ii) Section I— Coverage A— Bodily Injury (b) Not being used to carry persons or And Property Damage Liability does not property for a charge. apply to "bodily injury" or "property J. SUPPLEMENTARY PAYMENTS — INCREASED damage" that occurred before you LIMITS acquired or formed the organization, Section I — Supplementary Payments — partnership or limited liability company; Coverages A And Bp changed as follows: (iii)Section I—Coverage B—Personal And ra 1. The limit shown in Paragraph 1.b.for the cost Advertising Injury Liability does not g p apply to "personal and advertising injury" of bail bonds is changed from $250 to$3,000; arising out of an offense committed before and you acquired or formed the organization, 2. The limit shown in Paragraph 1.d. for loss of partnership or limited liability company; earnings because of time off from work is (iv) Coverage applies only when operations of changed from $250 a day to$1,000 a day. the newly acquired organization, K. UNINTENTIONAL OMISSION OR partnership or limited liability company are UNINTENTIONAL ERROR IN DISCLOSURE the same or similar to the operations of insureds already covered under this The following provision is added to Paragraph 6. insurance; Representations of Section IV — Commercial General Liability Conditions: (v) Coverage only applies for those limited liability companies who have established However, the unintentional omission of, or a date of formation as recorded within the unintentional error in, any information given or filed state articles of organization, provided by you shall not prejudice your rights certificates of formation or certificates of under this insurance. organization; and This provision does not affect our right to collect (vi) Coverage only applies for those additional premium or to exercise our right of partnerships who have established a date cancellation or non-renewal. of formation as recorded within a written L. WAIVER OF TRANSFER OF RIGHTS OF partnership agreement or partnership RECOVERY AGAINST OTHERS certificate. The following is added to Paragraph 8. Transfer H. WHO IS AN INSURED—AMENDMENT Of Rights Of Recovery Against Others To Us of The last paragraph of Section II — Who is An Section IV — Commercial General Liability Insured is deleted and replaced by the following: Conditions: No person or organization is an insured with We waive any right of recovery we may have respect to the conduct of any: against any person or organization because of payments we make for injury or damage arising a. Current partnership or limited liability out of your ongoing operations or"your work"and company, unless otherwise provided for under included in the "products-completed operations Paragraph 3. of Section II — Who Is An hazard" when you have agreed in a written Insured; contract or written agreement that any right of b. Current joint venture; or recovery is waived for such person or organization. This waiver applies only to the CL CG 04 92 10 18 Includes copyrighted material of Insurance Services Office, Inc., Page 7 of 8 with its permission person(s) or organization(s) agreed to in the written contract or written agreement and is subject to those provisions. This waiver does not apply unless the written contract or written agreement has been executed prior to the "bodily injury" or"property damage". However, if any person or organization is separately scheduled on a separate waiver of transfer of rights of recovery which is attached to this policy,then this waiver does not apply. M. LIBERALIZATION CLAUSE The following is added to Section IV — Commercial General Liability Conditions: If we adopt a mandatory attachment form change which broadens coverage under this edition of the Commercial General Liability CG0001 for no additional charge, and those changes are intended to apply to all insureds under this edition of CG0001,that change will automatically apply to your insurance as of the date we implement the change in your state. This liberalization clause does not apply to changes implemented through introduction of a subsequent edition of the Commercial General Liability form CG0001. N. INCIDENTAL MEDICAL MALPRACTICE 1. Paragraph 2.a.(1)(d) of Section II — Who Is An Insured does not apply to a physician, nurse practitioner, physician assistant, nurse, emergency medical technician or paramedic employed by you if you are not in the business or occupation of providing medical, paramedical, surgical, dental, x-ray or nursing services. 2. This provision is excess over any other valid and collectible insurance whether such insurance is primary,excess,contingent or on any other basis. Any payments by us will follow Paragraph 4.b. of Section IV — Commercial General Liability Conditions. CL CG 04 92 10 18 Includes copyrighted material of Insurance Services Office, Inc., Page 8 of 8 with its permission COMMERCIAL AUTO CL CA 20 93 03 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO ENHANCEMENT - PLATINUM PLUS This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SUMMARY OF COVERAGE EXTENSIONS Paragraph Name Of Extension Limit or No. Included A Additional Insured by Contract Or Agreement Including Primary and Included Noncontributory Other Insurance Condition B. Airbags-Extended Coverage Included C. Telematics&GPS Equipment Coverage $2,500 D. Electronic Equipment—Increased Coverage $2,500 E. Auto Loan/Lease Gap Coverage Unlimited F. Autos Rented by Employees Included G. Bail Bonds- Extended Coverage $5,000 H Broad Form Named Insured Including Newly Acquired or Formed Included Organizations I. Custom Signs& Decorations Included J. Employees as Insureds Included K. Family Emergency Travel Reimbursement $2,500 L. Fellow Employee Coverage Included M Fire Extinguisher Recharge Included N. Glass Repair—No Deductible Included O Hired Auto Physical Damage and Increased Loss of Use Expenses $100,000 Loss of use (Per Day/Maximum) $500/$3,500 P Hybrid Auto Payment Coverage (per auto/per loss) $2,500/$5,000 Q. Knowledge Of An Accident,Claim,Suit Or Loss Included R. Limited Worldwide Hired& Non Owned Auto Coverage Included S. Loss Of Earnings- Extended Coverage $1,000 T. New Vehicle Replacement Cost Included U. Rental Reimbursement Coverage Maximum Rental Expenses Per Day $75 Maximum Rental Expenses Because Of Loss To Any One Covered "Auto" $3,375 Maximum Rental Expenses Because Of Loss To All Covered "Autos" In $15,000 Any One Policy Period CL CA 20 93 03 19 Includes copyrighted material of Insurance Services Page 1 of 8 Offices,Inc.with its permission V. Personal Effects Coverage $500 W. Resultant Mental Anguish Included Towing And Labor Coverage Extension $200 X. Private Passenger Type $250 Other than Private Passenger Type Y. Transportation Expenses-Coverage Extension ( Per Day/Maximum) $75/$2,500 Z. Unintentional Failure To Disclose Hazards Included AA. Waiver Of Collision Deductible—Attached Autos Included BB. Waiver Of Subrogation By Contract Or Agreement Included A. ADDITIONAL INSURED BY CONTRACT OR 5. The following changes are made to AGREEMENT INCLUDING PRIMARY AND Paragraph 5. Other Insurance of B. NONCONTRIBUTORY OTHER INSURANCE General Conditions under Section IV — CONDITION Business Auto Conditions: The following is added to Paragraph A.1.Who Is a. The following is added to Paragraph 5.a.: An Insured of Section II — Covered Autos If required by the written contract or Liability Coverage: agreement described above, the When you have agreed in a written contract or insurance afforded to the additional agreement to include a person or organization as insured under this provision will be an additional insured, such person or primary to, and will not seek contribution organization is included as an"insured"subject to from, the additional insured's own the following: insurance. 1. Such person or organization is an b. Paragraph 5.c. is deleted in its entirety. additional insured only to the extent such 6. Paragraph A.1.c. under Section II - person or organization is liable for "bodilyCovered Autos Liability Coverage is injury" or "property damage"because of the deleted in its entirety. conduct of an "insured" under Paragraphs a. or b. under Paragraph A.1. Who Is An 7. The definition of "insured contract" under Insured of Section II — Covered Autos Section V — Definitions is amended to add Liability Coverage,caused by an "accident" the following: and resulting from the ownership, An "insured contract" does not include that maintenance or use of a covered "auto". part of any contract or agreement: That 2. The written contract or agreement pertains to the ownership, maintenance or described above must have been executed use of an "auto" and which indemnifies a prior to the "accident" that caused the person or organization for other than the "bodily injury" or "property damage"and be vicarious liability of such person or in effect at the time of such"accident". organization for "bodily injury" or "property 3. The insurance afforded to any such damage"caused by your operation or use of additional insured does not apply to any a covered "auto". "accident" beyond the period of time However,a person or organization is an additional required by the written contract or "insured" under this provision only to the extent agreement described above. such person or organization is not named as an 4. The most we will pay on behalf of such "insured"by separate endorsement to this policy. additional insured(s) is the lesser of: B. AIRBAGS- EXTENDED COVERAGE a. The Limits of Insurance specified in the Section III — Physical Damage Coverage, written contract or agreement Paragraph B.3.a. does not apply to the described above;or unintended discharge of an airbag. Coverage is b. The Limits of Insurance shown in the excess over any other collectible insurance or Declarations. warranty specifically designed to provide This provision shall not increase the Limit coverage. of Insurance shown in the Declarations in this policy or coverage part. Page 2 of 8 Includes copyrighted material of Insurance Services CL CA 20 93 03 19 Offices,Inc.with its permission C. TELEMATICS & GPS EQUIPMENT E. AUTO LOAN/LEASE GAP COVERAGE COVERAGE The following is added to Section III — Physical Damage Coverage is amended as Physical Damage Coverage, Paragraph C.: follows: In the event of a total "loss"to a covered "auto", 1. In Section III—Physical Damage Coverage, we will pay any unpaid amount due on the lease Paragraphs B.4.c. and B.4.d. do not apply or loan for a covered"auto", less: to: The amount paid under the Physical Damage a. Global positioning systems; or Coverage section of the policy;and any: b. "Telematics devices"; 1. Overdue lease/loan payments at the time of the"loss"; which are not: (1) Permanently installed in or upon the 2. Financial penalties imposed under a lease covered "auto"; for excessive use, abnormal wear and tear or high mileage; (2) Removable from a housing unit which is 3. Security deposits not returned by the lessor; permanently installed in or upon the covered "auto"; 4. Costs for extended warranties, Credit Life (3) An integral part of the same unit Insurance, Health, Accident or Disability housing any electronic equipment described Insurance purchased with the loan or lease; in Paragraphs a. and b.above; or; and (4) Necessary for the normal operation of 5. Carry-over balances from previous loans or the covered "auto" or the monitoring of the leases. covered "auto's"operating system. However, this provision does not apply to the 2. In the event of a "loss" to a covered "auto", extent loan/lease gap coverage has been the most we will pay for "loss" to global provided by separate endorsement to this policy. positioning systems and "telematics F. AUTOS RENTED BY EMPLOYEES devices" in any one covered "auto" is the The following is added to Section II — Covered lesser of: Autos Liability Coverage, Paragraph A.1.: a. The actual cash value of the damaged The following is added to the Who Is An Insured or stolen property at the time of loss; Provision: b. The cost of repairing or replacing An "employee" of yours is an "insured" while damaged or stolen property with other operating an "auto" hired or rented under a property of like kind and quality; or contract or agreement in an "employee's" name, c. $2,500 with your permission, while performing duties 3. For each covered "loss", a deductible of related to the conduct of your business $100 shall apply. G. BAIL BONDS- EXTENDED COVERAGE "Telematics Devices" include devices that are Section II—Covered Autos Liability Coverage, not installed by the vehicle manufacturer and Paragraph A.2.a.(2) is deleted and replaced by that are designed for the collection and the following: dissemination of data for the purpose of monitoring vehicle and/or driver performance. (2) Up to $5,000 for cost of bail bonds (including This includes global positioning systems and bonds for related traffic law violations) wireless safety communication devices. required because of an "accident" we cover. We do not have to furnish these bonds. Cellular, mobile and smart phones are not considered global positioning systems or "telematics devices"for purposes of this coverage provision. D. ELECTRONIC EQUIPMENT — INCREASED COVERAGE The $1,000 limit indicated in Paragraph C.1.b. under Section III— Physical Damage Coverage is increased to$2,500. CL CA 20 93 03 19 Includes copyrighted material of Insurance Services Page 3 of 8 Offices,Inc.with its permission H. BROAD FORM NAMED INSURED INCLUDING J. EMPLOYEES AS INSUREDS NEWLY ACQUIRED OR FORMED Section II- Covered Autos Liability Coverage, ORGANIZATIONS Paragraph A.1.b.(2) is deleted and replaced by The following is added to sub paragraph Al.Who the following: Is An Insured of Section II — Covered Autos (2) Any"employee"of yours is an"insured"while Liability Coverage: using a covered "auto"you don't own, hire or For any covered "auto"; borrow in your business or your personal affairs. Any organization, other than a partnership, joint However, insurance provided by this venture or limited liability company, over which rove ion, theI. EMPOYEES AS INSUREDS,by this you maintain ownership or majority interest of poes on, I. I if se S A Employee a more than 50 percent on the effective date of this apply p endorsement and for which you are obligated prior Insured coverage (or any similar or to the loss to provide insurance, unless that equivalent coverage) has been provided by a organization is an "insured" under any other separate endorsement issued by us and automobile policy or would be an "insured" under made a part of this policy or coverage part. such a policy but for the exhaustion of its Limit of K. FAMILY EMERGENCY TRAVEL Insurance. REIMBURSEMENT Any organization you newly acquire or form, other SECTION II - LIABILITY COVERAGE, A. 2. than a partnership, joint venture or limited liability Coverage Extensions is amended to include company or any organization excluded either by the following: this Coverage Part or by endorsement, and over In addition to the Limit of Insurance, we will pay which you maintain ownership or majority interest reasonable "travel reimbursement expenses" of more than 50 percent will qualify as a Named incurred by a "family member" or "designated Insured. However: representatives", of an "insured" or passenger 1. This insurance does not apply to any newly for travel to visit that "insured" or passenger acquired or formed organization that is an who was injured in an "accident" involving a "insured" under any other automobile policy or covered "auto", subject to the following would be an"insured"under such policy but for conditions: its termination or the exhaustion of its Limit of 1. Regardless of the number of traveling Insurance. "family members" or "designated 2. Coverage under this provision does not apply representatives", injured "insureds" or to "bodily injury", "property damage", expense passengers, claims made or vehicles or "loss" that occurred before you acquired or involved in the "accident", the most we will formed the organization. pay for all "travel reimbursement 3. Coverage under this provision is afforded only expenses" resulting from any one until the 180th day after you acquire or form the "accident" is $ 2,500. organization or the end of the policy period, 2. Travel must be to visit the injured party at the whichever is earlier. hospital to which such "insured" has been I. CUSTOM SIGNS & DECORATIONS admitted and has received medical or surgical treatment for a period of 72 hours or Physical Damage coverage on a covered "auto" extends to "loss" to custom signs and more from the time of first admittance to such hospital,or in the event of death,to the decorations including custom murals, paintings location necessary to handle the immediate or other decals or graphics. affairs of the deceased. Our limit of liability for each "loss" to custom 3. Subject to the $2,500 per accident limit, the signs and decorations shall be the least of: most we will pay for the combined total of (1) Actual cash value of the stolen or damaged expenses for room accommodations,meals, property;or and parking for each "family member" or (2) Amount necessary to repair or replace the "designated representatives" is $200 per property; day. This coverage does not apply to Hired Auto 4. We will reimburse ground transportation Physical Damage Coverage. using a personal vehicle at a rate of 40 cents Page 4 of 8 Includes copyrighted material of Insurance Services CL CA 20 93 03 19 Offices,Inc.with its permission per mile for the actual miles driven. M. FIRE EXTINGUISHER RECHARGE 5. All "travel reimbursement expenses" must The following is added to Paragraph A.4. be supported by written receipts submitted Coverage Extensions of Section III — to us no later than 120 days from the date Physical Damage Coverage: such "travel reimbursement expenses"were When fire extinguishers are kept in your covered incurred. "auto" and are discharged in an attempt to "Travel reimbursement expenses" include extinguish a fire, we will pay the lesser of the reasonable ground, rail, or air (coach class) actual cost of recharging or replacing such fire transportation, room accommodations, meals, extinguisher(s). and parking expenses only. No deductible applies to this coverage. "Designated representative" is an individual N. GLASS REPAIR—NO DEDUCTIBLE identified by the "insured" as a close personal friend or as having decision making authority Section III — Physical Damage Coverage, pertaining to the insured's care in the event of Paragraph D. is deleted and replaced by the incapacity or death. following: "Family member"means a person related to the D. DEDUCTIBLE injured "insured" by blood, marriage, state- For each covered "auto" our obligation to pay recognized civil union, or adoption, including a for, repair, return or replace damaged or stolen ward or foster child. property will be reduced by the applicable L. FELLOW EMPLOYEE COVERAGE deductible shown in the Declarations. Any Comprehensive Coverage deductible shown in Exclusion B. 5. of Section II - Covered Autos the Declarations does not apply to: Liability Coverage is deleted and replaced with the following: 1. "Loss"caused by fire or lightning; or 5. Fellow Employee 2. "Loss" when you elect to patch or repair a. "Bodily injury"to any fellow"employee"of glass rather than replace. an "insured" arising out of and in the O. HIRED AUTO PHYSICAL DAMAGE course of the fellow "employee's" COVERAGE AND INCREASED LOSS OF USE employment or while performing duties EXPENSES related to the conduct of your business; Section III — Physical Damage Coverage, A. 4 or Coverage Extensions is amended to include the b. The spouse, child, parent, brother or following: sister of that fellow "employee" as a If hired "autos" are covered "autos" for Liability consequence of Paragraph a. above. Coverage under this g policy and if Physical However, this exclusion does not apply to Damage Comprehensive Coverage, Physical liability incurred by your"employees"that are Damage Specified Causes Of Loss Coverage, or "executive officers". Physical Damage Collision Coverage is provided No "employee" is an "insured" for "bodily under this policy for any "auto" you own, then injury" to a co-employee if such co- such Physical Damage Coverages are extended employee's exclusive remedy is provided to apply to "autos" you lease, hire, rent or borrow under a workers compensation law or any without a driver, subject to the following similar law. provisions: For the purpose of Fellow Employee Coverage 1. This extension is only available for "autos" only, paragraph B.5. of Business Auto you lease, hire, rent or borrow for less than Conditions is changed as follows: 30 consecutive days. This FELLOW EMPLOYEE COVERAGE is 2. The most we will pay in any one "loss" is the excess over any other collectible insurance. least of $100,000, the actual cash value of As used in this provision, "executive officer" the "auto" or the cost to repair or replace means a person holding any of the officer the"auto", except that such amount will be positions created by your charter, constitution, reduced by a deductible to be determined as by-laws or any other similar governing document. follows: a. The deductible shall be equal to the CL CA 20 93 03 19 Includes copyrighted material of Insurance Services Page 5 of 8 Offices, Inc.with its permission amount of the highest deductible 2. For the purpose of this coverage provision shown for any owned "auto" of the the following Definitions are added: same classification for that coverage. a. "Hybrid auto" is defined as an "auto", In the event there is no owned "auto" including a hybrid "electric auto" that is of the same classification, the highest powered by two sources, an internal deductible for any owned "auto" will combustion engine, and an electric apply for that coverage. motor. b. No deductible will apply to "loss" b. "Electric auto" is an "auto" that is caused by fire or lightning. powered by an electric motor instead of 3. Coverage provided under this extension will an internal combustion engine. The be excess over any other collectible "electric auto" uses energy stored in its insurance you have. rechargeable batteries, which are recharged by common household Paragraphs 1 through 3 above do not apply if electricity. separate Hired Auto Physical Damage is indicated in the declarations. Cl. KNOWLEDGE OF AN ACCIDENT, CLAIM, 4. For"autos" you lease, hire, rent or borrow SUIT OR LOSS covered under this Hired Auto Physical The following is added to Section IV—Business Damage Coverage extension or under Auto Conditions, Paragraph A.2.: separate coverage provided in the Notice of an "accident" or "loss" will be declarations, the limits in subparagraph b. considered knowledge of yours only if reported Loss Of Use Expenses under paragraph 4. to you, if you are an individual, a partner, an Coverage Extensions as found in executive officer or an employee designated by paragraph A. Coverage of SECTION III — you to give us such notice. PHYSICAL DAMAGE COVERAGE, are Notice of an"accident"or"loss"to your Workers' increased to $500 per day, to a maximum Compensation insurer, for an event which later of$3,500. develops into a claim for which there is coverage P. HYBRID AUTO PAYMENT COVERAGE under this policy, shall be considered notice to Section III — Physical Damage Coverage, A. 4 us, but only if we are notified as soon as you Coverage Extensions is amended to include the know that the claim should be addressed by this following: policy, rather than your Workers' Compensation policy. 1. In the event of a total "loss" to a non-"hybrid R. LIMITED WORLDWIDE HIRED& NON OWNED auto" for which Comprehensive, Specified AUTO COVERAGE Causes of Loss, or Collision coverages are provided under the Business Auto Coverage In Section IV - Business Auto Conditions, form, then Physical Damage Coverages are Condition B.7., paragraph b.(5) is replaced by amended as follows: the following: a. If a non-"hybrid auto" is replaced with a (5) Anywhere in the world if a covered "auto" is "hybrid auto"or"electric auto"we will pay leased, hired, rented or borrowed without a an additional 10% of the non-"hybrid driver for a period of 30 days or less, auto's"actual cash value or replacement S. LOSS OF EARNINGS - EXTENDED cost,to a maximum of$2,500,whichever COVERAGE is less; Section II — Covered Autos Liability b. The non-"hybrid autos" must be replaced Coverage, Paragraph A.2.a.(4) is deleted and and a copy of a bill of sale or lease replaced by the following: agreement must be received by us within (4) All reasonable expenses incurred by the 60 calendar days of the date of "loss"; "insured"at our request, including actual loss and of earnings up to $1,000 a day because of c. If more than one non-"hybrid auto" is time off from work. damaged in any one "loss", the most we will pay under this Coverage for any one "loss"is$5,000. Page 6 of 8 Includes copyrighted material of Insurance Services CL CA 20 93 03 19 Offices,Inc.with its permission T. NEW VEHICLE REPLACEMENT COST (2) The maximum rental expenses The following is added to the Paragraph C. Limit shown below: of Insurance provision of Section III— Physical (a) $3,375 because of "loss" to Damage Coverage: any one covered"auto"; In the event of a total "loss"to your"new vehicle" (b) $15,000 because of all "loss"to to which this coverage applies,we will pay at your all covered "autos" in any one option: policy period. a. The cost to replace the covered "auto"with a 4. We will pay up to an additional $300 for new"auto"of like make, model and year; or the reasonable and necessary expenses b. An amount equal to the original purchase you incur to remove your materials and price you paid to acquire the vehicle, equipment from the covered "auto" and including taxes, but excluding any extended replace such materials and equipment on warranties and licensing fees. the rental"auto". This coverage applies only to a covered "auto"of 5. This coverage does not apply while there the private passenger, light truck or medium truck are spare or reserve "autos" available to type (20,000 lbs. or less gross vehicle weight). you for your operations. 6. If"loss"results from the total theft of a covered As used in this endorsement, a "new vehicle" "auto" of the private passenger type, we will means an "auto" of which you are the original pay under this coverage only that amount owner that has not been previously titled and of your rental reimbursement expenses which you purchased less than 180 days before which is not already provided for under the the date of the"loss". Physical Damage Coverage Extension. U. RENTAL REIMBURSEMENT COVERAGE V. PERSONAL EFFECTS COVERAGE 1. We will pay for rental reimbursement The following is added to Section III—Physical expenses incurred by you for the rental of an Damage Coverage, Paragraph A.4.: "auto" because of "loss" to a covered "auto". Payment applies in addition to the Physical Damage Coverage on a covered"auto" otherwise applicable amount of each is extended to "loss" to your personal property coverage you have on a covered "auto". No and, if you are an individual, the personal deductible applies to this coverage. This property of a family member, that is in the coverage is only available to those covered covered"auto"at the time of"loss"; and caused "autos" involved in a "loss" and Physical by an "accident" and resulting from the Damage is provided to the covered "auto". ownership, maintenance or use of a covered 2. We will pay only for those expenses "auto". incurred during the policy period, The most we will pay for any one "loss" under beginning 24 hours after the "loss" and this coverage extension is $500. However, our ending, regardless of the expiration date of payment for "loss" to personal property will the policy, with the lesser of the following; only be for the account of the owner of the property. 1. The number of days reasonably required to repair or replace the Under this provision personal property does not include and we will not pay for"loss"of: covered "auto". If "loss" is caused by theft,this number of days is added to the 1. Currency, coins,securities or number of days it takes to locate the 2. Property that under federal or state law is covered"auto"and return it to you;or a. An illegal controlled substance 2. 45 days. b. Property in the course of illegal 3. Our payment is limited to the lesser of transportation or trade. the following amounts: No deductible applies to this coverage extension. 1. Necessary and actual expenses incurred. 2. The maximum rental expenses indicated below: (1) Not more than $75 per day; CL CA 20 93 03 19 Includes copyrighted material of Insurance Services Page 7 of 8 Offices, Inc.with its permission W. RESULTANT MENTAL ANGUISH AA.WAIVER OF COLLISION DEDUCTIBLE — Section V-Definitions, Paragraph C. is deleted ATTACHED AUTOS and replaced by the following: The following is added to paragraph D. under C. "Bodily injury" means bodily injury, disability, SECTION III - PHYSICAL DAMAGE sickness, or disease sustained by a person, COVERAGE of the Business Auto Coverage including death resulting from any of these at Form: any time. "Bodily injury" includes mental If a"trailer"is connected to an"auto"that is not a anguish or other mental injury resulting from "trailer"and both "autos": "bodily injury". 1. Are covered "autos" for Collision Coverage X. TOWING AND LABOR COVERAGE that applies to that"accident",and EXTENSION 2. Sustain damage in a single"accident". The following is added to Section III — Physical we will waive the lowest of the applicable Collision Damage Coverage, paragraph A.2.: deductibles. 1. We will pay up to: BB.WAIVER OF SUBROGATION BY a. $200 for a covered "auto" of the private CONTRACT OR AGREEMENT passenger type or The following is added to Section IV - b. $250 for a covered "auto" that is not of Business Auto Conditions, Paragraph A.5.: the private passenger type, for towing and labor costs incurred each time We waive any right of recovery we may have the covered "auto" is disabled. However,the against any "insured" provided coverage under labor must be performed at the place of this endorsement under A. ADDITIONAL disablement. INSURED BY CONTRACT OR AGREEMENT 2. This coverage applies only for an "auto" INCLUDING PRIMARY AND covered on this policy for Comprehensive or NONCONTRIBUTORY OTHER INSURANCE Specified Causes of Loss Coverage and CONDITION, but only as respects "loss"arising Collision Coverages. out of the operation, maintenance or use of a 3. Payment applies in addition to the otherwise covered "auto" pursuant to the provisions or applicable amount of each coverage you conditions of the written contract or agreement. have on a covered "auto". Y. TRANSPORTATION EXPENSES-COVERAGE EXTENSION Paragraph A.4.a. Transportation Expenses of Section III — Physical Damage Coverage is amended as follows: 7. The Limits of Insurance are increased to $75 per day to a maximum of$2,500. 8. We will also pay reasonable and necessary expenses to facilitate the return of the stolen "auto"to you. Z. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS The following is added to Section IV- Business Auto Conditions, Paragraph B.2.: If you unintentionally fail to disclose any hazards existing at the inception of this policy, such failure will not prejudice the coverage provided to you. However,this provision does not affect our right to collect additional premium or exercise our right of cancellation or nonrenewal. Page 8 of 8 Includes copyrighted material of Insurance Services CL CA 20 93 03 19 Offices,Inc.with its permission DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/13/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER Tara Earley NAME: FAX PHONE (800)563-1871(785)825-5098 Assurance Partners (A/C, No): (A/C, No, Ext): E-MAIL tearley@yourassurance.com 201 E Iron St. ADDRESS: P.O. Box 1213 INSURER(S)AFFORDINGCOVERAGE NAIC# Salina KS 67402-1213 Nationwide Mutual Insurance Company23787 INSURER A : INSURED Kansas Builders' Insurance Group0010 INSURER B : Lancaster Construction, Inc. INSURER C : 618 Francis Ave INSURER D : INSURER E : Salina KS 67401-2448 INSURER F : 16.17 Pkg/17.18 WC COVERAGES CERTIFICATENUMBER:REVISIONNUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDLSUBR INSR POLICY EFF POLICY EXP TYPE OF INSURANCE LIMITS POLICY NUMBER LTR(MM/DD/YYYY)(MM/DD/YYYY) INSDWVD COMMERCIAL GENERAL LIABILITY X 1,000,000 EACHOCCURRENCE$ DAMAGE TO RENTED 100,000 CLAIMS-MADE OCCUR$ A X PREMISES(Eaoccurrence) X ACP7260073862 12/28/201612/28/2017 5,000 MEDEXP(Anyone person)$ 1,000,000 PERSONAL&ADVINJURY$ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ PRO- X 2,000,000 POLICY LOC PRODUCTS - COMP/OP AGG$ JECT $ OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY $ 1,000,000 (Eaaccident) BODILYINJURY(Perperson)$ X ANY AUTO A ALLOWNED SCHEDULED BODILYINJURY(Peraccident)$ ACP7260073862 12/28/201612/28/2017 X AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X X HIRED AUTOS (Peraccident) AUTOS $ UMBRELLA LIAB X X EACHOCCURRENCE$ OCCUR 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE$ 1,000,000 A 12/28/2016 X ACP7260073862 12/28/2017 $ 0 DED RETENTION$ PER OTH- WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACHACCIDENT$ 1,000,000 N / A OFFICER/MEMBER EXCLUDED? 1/1/2017 B 20171191 1/1/2018 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE$ 1,000,000 If yes,describeunder E.L. DISEASE - POLICY LIMIT$ DESCRIPTION OF OPERATIONS below 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CG7323, AC7004 Project No. 63086, Greeley Avenue Sidewalk CERTIFICATE HOLDER CANCELLATION coi@salina.org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salina ACCORDANCE WITH THE POLICY PROVISIONS. 300 W Ash Salina, KS 67401 AUTHORIZED REPRESENTATIVE Susan Flaming/SFLAMI ©1988-2014ACORD CORPORATION.Allrights reserved. ACORD25(2014/01)TheACORD nameand logoare registeredmarks ofACORD INS025(201401) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/23/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT Roberta Blair PRODUCER NAME: FAX Assurance Partners PHONE (800)563-1871 (785)825-5098 (A/C, No): (A/C, No, Ext): E-MAIL 201 E Iron St. rblair@yourassurance.com ADDRESS: P.O. Box 1213 INSURER(S)AFFORDINGCOVERAGENAIC# SalinaKS67402-1213 Nationwide Mutual Insurance Co 23787 INSURER A : KBIWCF 0010 INSURED INSURER B : Lancaster Construction, Inc. INSURER C : 618 Francis Ave INSURER D : INSURER E : SalinaKS67401-2448 INSURER F : 14.15Pkg 15.16WC COVERAGESCERTIFICATENUMBER:REVISIONNUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDLSUBR INSRPOLICY EFFPOLICY EXP TYPE OF INSURANCELIMITS POLICY NUMBER (MM/DD/YYYY)(MM/DD/YYYY) LTR INSRWVD 1,000,000 GENERAL LIABILITY EACHOCCURRENCE$ DAMAGE TO RENTED X 100,000 COMMERCIAL GENERAL LIABILITY$ PREMISES(Eaoccurrence) 12/28/201412/28/2015 AXY 5,000 X ACP7240073862 CLAIMS-MADEOCCURMEDEXP(Anyoneperson)$ 1,000,000 PERSONAL&ADVINJURY$ 2,000,000 GENERAL AGGREGATE$ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:PRODUCTS - COMP/OP AGG$ PRO- X $ POLICYLOC JECT COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY 1,000,000 (Eaaccident)$ BODILYINJURY(Perperson)$ ANY AUTO A X ALLOWNEDSCHEDULED ACP7240073862 12/28/201412/28/2015 XY BODILYINJURY(Peraccident)$ AUTOSAUTOS XX NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS (Peraccident) AUTOS $ XX 1,000,000 UMBRELLA LIAB EACHOCCURRENCE$ OCCUR 1,000,000 EXCESS LIAB A CLAIMS-MADEAGGREGATE$ X 12/28/201412/28/2015 ACP7240073862 0 $ DEDRETENTION$ BY WC STATU-OTH- WORKERS COMPENSATION X TORY LIMITSER AND EMPLOYERS' LIABILITY Y / N 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACHACCIDENT$ N / A OFFICER/MEMBER EXCLUDED? 1/1/20151/1/2016 20151191 1,000,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE$ Ifyes,describeunder 1,000,000 E.L. DISEASE - POLICY LIMIT$ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Project No. 13-2988 Concrete Drives and Sidewalks at WW Pump Stations. City of Salina is named as an additional insured to general liability and auto liability. General Liability additional insured includes completed ops. Waiver of Subrogation is added to general liability, auto liability and workers' compensation for City of Salina as allowed by state statute. CERTIFICATE HOLDERCANCELLATION coi@salina.org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Salina 300 W. Ash AUTHORIZED REPRESENTATIVE Salina, KS 67401 Susan Flaming/SFLAMI ACORD25(2010/05)©1988-2010ACORDCORPORATION.Allrightsreserved. INS025 TheACORDnameandlogoareregisteredmarksofACORD (201005).01