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Insurance Certificate CANCELLATION/NONRENEWAL NOTICE Page 1 of 1 Third Party Copy ADDITIONAL INSURED Account Number: 235-481-9 Date: 02/17/2021 Place of Issue: FEDERATED INSURANCE Insured: - 121 East Park Square P28 TRINC t P (1- O Box 1334A N OHIO ST � r Owatonna,� ) MN 55060 SALINA, KS 67401-2405 (���'V Cancellation/Nonrenewal of each policy listed below was requested by the insured. According to contract language in the policies listed below, we will continue to protect your interest as a mortgagee, additional insured, or a loss payee through the date and time of day shown below. Policy Time of Policy Cancellation/Nonrenewal Policy Number Policy Type Date Cancellation/Nonrenewal* 6062489 Commercial Package Policy 01/07/2021 _ 12:01 a.m. 6064179 Employment Related Pract 01/07/2021 12:01 a.m. 6062490 Umbrella 01/07/2021 12:01 a.m. 6062491 Worker's Compensation 01/07/2021 12:01 a.m. * Standard time at the designated business premises. CITY OF SALINA DEPARTMENT OF COMMUNITY Loss Payee/ & DEVELOPMENT SRVC BUILDING SRVC DIVISION Mortgagee/ 300 W ASH ST RM 205 Additional Insured/ SALINA, KS 67401-2335 Certificate Holder FEDERATED MUTUAL INSURANCE COMPANY • FEDERATED SERVICE INSURANCE COMPANY* •FEDERATED RESERVE INSURANCE COMPANY* MFO-40 (08-17) federatedinsurance.com I *Not licensed in all states. I 1-888-333-4949 '4 DA'E( 1 CERTIFICATE OF LIABILITY INSURANCE ,2/0812020 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 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). PRODUCER CONTACT NAME: CLIENT CONTACT CENTER FEDERATED MUTUAL INSURANCE COMPANY PHONE HOME OFFICE:P.O.BOX 328 (A/C,No,Ext):888-333-4949 (A/C,No):507446-4664 OWATONNA,MN 55060 ADDRESS:E-ML ACLI ENTCONTACTCENTER(a(FEDINS.COM INSURERS)AFFORDING COVERAGE NAIC# INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 235-481-9 INSURER B: TRR INC,T&R DIRT CONSTRUCTION,AMERICAN ROLL-OFF SERVICES INSURER C: 1334A N OHIO ST SALINA,KS 67401-2405 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:86 REVISION NUMBER:0 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. INSRI TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR 'NSR WVD IMM/DD/YYYYI (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $100,000 MED EXP(Any one person) EXCLUDED A N N 6062489 01/07/2021 01/07/2022 PERSONAL ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE $2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGO $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE OMIT $1,000,000 (Ea accident) X ANY AUTO BODILY INJURY Per person) —OWNED AUTOS ONLY SCHEDULED A _AUTOS N N 6062489 01/07/2021 01/07/2022 BODILY INJURY Per accident HIRED AUTOS ONLY NON-OWNED PROPERTY DAMAGE _AUTOS ONLY (Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $5,000,000 A EXCESS LIAB CLAIMS-MADE N N 6062490 01/07/2021 01/07/2022 AGGREGATE $5,000,000 DED 'RETENTION WORKERS COMPENSATIONX PER STATUTE OTH- ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 A OFFICER/MEMBER EXCLUDED? NIA N 6062491 01/07/2021 01/07/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) CERTIFICATE HOLDER CANCELLATION 235-481-9 86 0 CITY OF SALINA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 300 W ASH,RM 206 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN PO BOX 736 ACCORDANCE WITH THE POLICY PROVISIONS. SALINA,KS 67402-0736 AUTHORIZED REPRESENTATIVE 1 O 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2018103) The ACORD name and logo are registered marks of ACORD A CERTIFICATE OF LIABILITY INSURANCE r DATE01/1 2018 Y 01/182018 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: It 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). PRODUCER CONTANAME: CLIENT CONTACT CENTER FEDERATED MUTUAL INSURANCE COMPANY PHONE FAX HOME OFFICE: P.O. BOX 328 (A/C,No,Eat):888-333-4949 (A/C,No):507-446-4664 OWATONNA,MN 55060 n EDRESS:CLIENTCONTACTCENTERQoFEDINS.COM _ INSURER'S)AFFORDING COVERAGE NAIC# INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 235-481-9 INSURER B: T&R DIRT CONSTRUCTION,AMERICAN ROLL-OFF SERVICES, INC. INSURER C: 1334A N OHIO ST SALINA, KS 67401-2405 INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:29 REVISION NUMBER:2 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. ' LJCY EXP LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER (mm/DDDIYYYYI I (MF MIDDIYYYYI _LIMITS X COMMERCIAL GENERALUABIUTY EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED $100,000 PREMISES(Ea occurrence) MED EXP(Any one person) EXCLUDED A Y Y 6062489 01/07/2018 01/07/2019 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATEGAUMIT AIIPP�UES PER: . GENERAL AGGREGATE $2,000,000 _IPOUCY I I SECT 1 I LOC PRODUCTS-COMP/OP AGG $2,000,000 'OTHER: - _ , _ AUTOMOBILE LIABILITY COMBINED SINGLE UMIT $1 000000 (Ea accident X ANY AUTO BODILY INJURY(Per perm) OWNED AUTOS ONLY SCHEDULED A AUTOS N N 6062489 01/07/2018 01/07/2019 BODILY INJURY(Per accident) HIRED AUTOS ONLY NON-OWNED PROPERTY DAMAGE AUTOS ONLY Per accident) X I UMBRELLA LIAB I X OCCUR EACH OCCURRENCE $2,000,000 A EXCESS LIAB CLAIMS-MADE N N 6062490 01/07/2018 01/07/2019 AGGREGATE $2,000,000 I DED 'RETENTION WORKERS COMPENSATION l l X PER STATUTE OTH- AND EMPLOYERS'LIABILITY Y/N ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L EACH ACCIDENT $500,000 A OFFICER/MEMBER EXCLUDED? I 'NIA N 6062491 01/07/2018 01/07/2019 (ManAatory in NH) E.L DISEASE.EA EMPLOYEE $500000 II Yes,describe under DESCRIPTION OF OPERATIONS-below----- I — - - _ _ ,. _ _ - - __ _ E.L DISEASE-POUCY UMIT $500,000 1 , DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be affitlied II more space is required) SEE ATTACHED PAGE • - - CERTIFICATE HOLDER CANCELLATION 235-481-9 29 2 CITY OF SALINA PUBLIC WORKS DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO BOX 736 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN • SALINA, KS 67402-0736 ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE 9#47"11 --- O 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 235-481-9 LOC#: ACORO® ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED FEDERATED MUTUAL INSURANCE COMPANY T 8 R DIRT CONSTRUCTION,AMERICAN ROLL-OFF SERVICES, INC. POLICY NUMBER 1334A N OHIO ST SEE CERTIFICATE#29.2 SALINA, KS 67401-2405 CARRIER NAIC CODE SEE CERTIFICATE#29.2 EFFECTIVE DATE:SEE CERTIFICATE #29.2 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE ADDITIONAL NAMED INSUREDS INCLUDE TRR INC RE: PROJECTS 80014 - CENTENNIAL PARK CONCRETE REMOVE AND REPLACE THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU ENDORSEMENT FOR GENERAL LIABILITY. GENERAL LIABILITY CONTAINS A WAIVER OF SUBROGATION IN FAVOR OF THE CERTIFICATE HOLDER SUBJECT TO THE CONDITIONS OF THE BLANKET WAIVER OF TRANSFER OF RIGHTS OF RECOVERY ENDORSEMENT. GENERAL LIABILITY COVERAGE CONTAINS CG 25 03 DESIGNATED CONSTRUCTION GENERAL AGGREGATE LIMIT ENDORSEMENT APPLICABLE TO EACH CONSTRUCTION PROJECT AS REQUIRED BY WRITTEN CONTRACT OR WRITTEN AGREEMENT. • ACORD 101 (2008101) 0 2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD AC ® DATE IMWDM'YYYI ` CERTIFICATE OF LIABILITY INSURANCE 1/5/2015 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 pollcy(les)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). PRODUCER Hw/O�ic�ME�MAC'Emily White Assurance Partners PHONE pa). (000)563-1871 FAX xm I7e51 025-509e 201 B Iron St. AwRFSR.ewbite@yourassurance.con P.G. Box 1213 INSURER(S)AFFORDING COVERAGE NAICF Salina KS 67402-1213 INSURER A:EMCASCO Insurance Company 21407 INSURED INSURER B:KBIWCF 0010 TAR Dirt Construction, DBA: TER, Inc. INSURER C: 1334A N Ohio INSURER D: PG Box 542 INSURERE: - Salina KS 67402-0592 INSURER F: COVERAGES CERTIFICATE NUMBER 15/16 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. SR ADOL SUER POLICY EPF POLICY EXP LIMITS INSR TYPE OF INSURANCE 1 R WVD POLICY NUMBER IMWDLNYYVYI IMWODIYYYI, GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAXE TO X COMMERCIAL GENERAL LIABILITY PREMISES IEF occurrence) $ 100,000 A I CLAIMS-MADE X OCCUR X 3%52921 1/7/2015 1/7/2016 MED EXP(Any one person) 1 5.000 PERSONAL&ADV INJURY 5 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENL AGGREG ATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000.000^ in POLICY JEST LOC $ CVMtlINEI]SMGLE LIMB AUTOMOBILE LIABILITY (Ea accident) S 1,000.000 X ANY AUTO BODILY INJURY(Per peeon) S A ALL OWNED SCHEDULED X 3X82821 1/7/2015 1/7/2016 BODILY INJURY{Per accident) $ AUTOS AUTOS PROPERTY DAMAGE X HIRED AUTOS X 21"1,2S"ED (Per accident) $ Uninsured mmonst BI-single $ 1,000,000 UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 — A K EXCESS LIAR CLAIMS-MADE AGGREGATE $ 2,000,000 OED X RETENTION$ 10,000 3X82921 1/7/2015 1/7/2016 $ E WORKERS COMPENSATION TORY IMTS I IOFR AND EMPLOYERS'LIABILITY ANY PROPRIE TOR/PARTNER/EXECUTIVE YIN NIA EL EACH ACCIDENT S 500,000 MandRIMEnNHI EXCLUDED? 20161773 1/1/2015 1/1/2016 EL DISEASE-EA EMPLOYEE 5 500,000 OFFICE Dry In NN DESCRIPTION OF OPERATIONS below E L.DISEASE.POLICY LIMIT I. 500,000 DESCNPT ON OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 1E1.Additional RemaMe Schedule,Imon space Is required) City of Salina is named as an additional insured for General Liablity I Auto as regards work performed by TAR Dirt Construction. General Liability is primary/non contributory and includes completed operations. Pollution Liability: Writing company American Safety Indemnity Co., Limit: $1,000,000, Deductible: $5,000 This is an amended certificate and aupercedes any previously issued certificate. CERTIFICATE HOLDER CANCELLATION coltsalina.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 PO Box 736 AUTHORIZED REPRESENTATVE Salina, KS 67402-0736 Emily White/EMILYN t t,._ -. ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INR025nntllnsl n, Tha Arn im Hama end Innn am ranlamred marLa AI an ion