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Insurance Certificate A ROC O® CERTIFICATE OF LIABILITY INSURANCE DATE(MMO /Y DYYY) 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 MARSH USA INC. NAME: HONE FAX 540W.MADISON IANC No Ertl: INC.No): CHICAGO,IL 60661 E-MAIL Attn:Chicago.CertRequesl@mamsh.a ADDRESS: n1 INSURER(S)AFFORDING COVERAGE HNC Y KS793 INSURER A:ACE American Insurance Company 22667 INSURED INSURER B:ACE Fire Underwnt&Js Company 20702 KINE SHOP,INC. 734 E.FOURTH STREET INSURER C:Indemnity Insurance Company of North America 43575 HUTCHINSON,KS 67501 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CHI-007845407-11 REVISION NUMBER: 11 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 TYPE OF INSURANCE ADOLIMNSUBR POLICY EFF POLICY EXP LIMITS LTR ?NSD WVD POLICY NUMBER IMDDNYYY) IMMJDD/VYYYI A X COMMERCIAL GENERALLIABIUTY XSL 627873509 01252018 01252019 EACH OCCURRENCE S 2,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea ocaarertce) $ 500,000 X Liquor Liabdty:51,000,000 MED EXP(Any ore person) S WA- X DR199615 Professional PERSONAL B ADV INJURY S 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3,000,000 X 1 POLICY jEa LOC PRODUCTS-COMP/OP AGG S 3.000,000 X OTHER: SIR 53MIL S ISA H25098316 012512018 01/292019 COMBINED SINGLE LIMIT s 5,000,090 A AUTOMOBILE LIABILITY - (Ea accident) X ANY AUTO BODILY INJURY(Par person) S OWNED SCHEDULED BODILY INJURY(Per aothaent) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY (Per accident) PHYSICAL DAMAGE S SELF-INSURED I UMBRELLA LIAR _ OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE S DED I RETENTIONS S C WORKERS COMPENSATION WLR C64781790(AOS) 0125/2018 01252019 x PER OTH- ANDEMPLOYERS'LIABRITY STATUTE ER B ANYPROPRIETORNPARTNER/EXECUTNE Y(� NIA SCF 064624105(Retro) 01252018 012Y1019 E.L.EACH ACCIDENT S 3 000,000 OFFICER/MEMBER EXCLUDED? I I (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 3,000,000 If yes,describe under 3,000,000 DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT S A EXCESS WORKERS COMP. WCU C64624027 0125/2018 01252019 EL:EA.ACCIDENT 1,000,000 SIR:55,000,000 EL:DISEASE/EA EMPLOYEE 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS N VEHICLES(ACORD 101,Additional Remade Schedule,may be attached If more space Is required) Re:K.0 Shop 793,1727 West Crawford,Salina,KS 67401 City of Sa5na is Included as Adddonal Insured on the General LiabTily as required by written contract. Coverage is Primary and Non-ConMhoiory,tut only as required by widen conirad. CERTIFICATE HOLDER CANCELLATION City of Sada,Kansas SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE do Cly Clerk THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 736 ACCORDANCE WITH THE POLICY PROVISIONS. Sarna,KS 67402-0736 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee J acnao-i .u.-c4- ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 806816 LOC#: Chicago AC o® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA INC. KWIK SHOP,INC. 734 E.FOURTH STREET POUCY NUMBER HUTCHINSON,KS 67501 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance The Kroger Co.or its designee will endeavor to mai 30 days'nonce of cancellaton(or 10 days for non-payment)to the certificate holder. Such notice is nota right or obtgatiw within the pokies,it does rot alter air amend any coverage,it we rot extend any poky cancellation date and it we rot negate any calcellabon of the policy.Failure o provide a copy of such rake ld the Cenkae Holder shat use no otEgation or tiabitdy of any kind upon the insurer or its agents or representatives. ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. • The ACORD name and logo are registered marks of ACORD AFRO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/21/2016 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). PRODUCER CONTACT MARSH USA INC. NAME: -_ PHONE 540 W.MADISON INC,No.Ext): FAX No): CHICAGO,IL 60661 E-MAIL ADDRESS: Attn:Chicago.CertRequest@marsh.com — — --INSURER(S)AFFORDING COVERAGE _ NAIC# KS793 INSURER A:ACE American Insurance Company 22667 INSURED KWIK SHOP,INC. INSURER B 734 E.FOURTH STREET INSURER C: _ HUTCHINSON,KS 67501 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CHI-005455029-05 REVISION NUMBER:10 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 TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY XSL G27403499 01/25/2016 01/25/2017 EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED _PREMISES(Ea occurrence) $ 500,000 X Liquor Liability& MED EXP(Any one person) $ N/A X Druggists Professional PERSONAL&ADV INJURY $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE _ $ 3,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 3,000,000 X OTHER: SIR$3MIL $ A AUTOMOBILE LIABILITY ISA H08866971 01/25/2016 01/25/2017 COMBINED SINGLE LIMIT $ 5,000,000 (Ea accident) X _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) —_ PHYSICAL DAMAGE $ SELF-INSURED UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WLR C4859752A(AOS) 01/25/2016 01/25/2017 x PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE YN N N/A SCF C48597567(Retro-WI Only) 01/25/2016 01/25/2017 E.L EACH ACCIDENT $ 3,000,000 OFFICER/MEMBER EXCLUDED? - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 3,000,000 If yes,describe under 3,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A EXCESS WORKERS COMP. WCU C48597440 01/25/2016 01/25/2017 EL:EA.ACCIDENT 1,000,000 SIR:$5,000,000 EL:DISEASE/EA EMPLOYEE 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Re:Kwik Shop 793,1727 West Crawford,Salina,KS 67401 City of Salina is included as Additional Insured on the General Liability as required by written contract Coverage is Primary and Non-Contributory,but only as required by written contract. CERTIFICATE HOLDER CANCELLATION City of Salina,Kansas SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCE(.LED BEFORE Go City Clerk THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 736 ACCORDANCE WITH THE POLICY PROVISIONS. Salina,KS 67402-0736 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee _i ..a,.,n,uc>1... -..)4-,4.44.'-e^ir 't. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: S06816 _ LOC#: Chicago A /e°® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA INC. KWIK SHOP,INC. 734 E.FOURTH STREET POLICY NUMBER HUTCHINSON,KS 67501 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance The Kroger Co.or its designee will endeavor to mail 30 days'notice of cancellation(or 10 days for non-payment)to the certificate holder. Such notice is not a right or obligation within the policies,it does not alter or amend any coverage,it will not extend any policy cancellation date and it will not negate any cancellation of the policy.Failure to provide a copy of such notice to the Certificate Holder shall impose no obligation or liability of any kind upon the insurer or its agents or representatives. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION Named Iraurt'.i Fndrn:Faraerrt Nun'Der The Kroger Go 4 Policy Sym`x• Pcr i:y Vurnter Policy Period Eifec:Ive Date of Encorsemenl XSL j G27403499 01125/2016 to 01/25/2017 ss red ey Name of Ins renc.a Cornpeny) ACE American Insurance Company nsorl Jr,1 i ,!I:y-n.m:,er. 1 he ramai Icier of the infer-nation a to be ccmpleed only v,wn f'rls unr,e- nrn'e.i ssac-:1 suhcac.ient to the preaaradce of the potley. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY SCHEDULE • Name of Person or Organization: Any person or organization whom you have agreed to include as an additional insured under a written contract, provided such contract was executed prior to the date of loss. A. Section 11 - Who Is An Insured is arnended to include as an additional insured the person(s) or organization(s) shown in the Schedule but only with respect to liability for "bodily injury". "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or '1 2. in connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance And Retained Limit: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less, This endorsement shall not increase the applicable Limits of lnsu :n shown in the Dee i,raliuns. : :.. . � Authorized Representative XS-6W2Sb(04/13) Includes copyrighted material of Insurance Serv,ees Offico, Inc..with its perrniss on. Page 1 of 1