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Insurance AC�® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/21/2016 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 Paige Sexton NAME: g Shepherd Insurance, LLC. (A//�No,Ext): (31 7)846-5554 FAX No): (317)846-5444 111 Congressional Boulevard ADMDRESS:pnsexton @shepherdins.com Suite 100 INSURER(S)AFFORDING COVERAGE NAIC 4 Carmel IN 46032 INSURERAACUITY 14184 INSURED INSURERB:Crum & Forster Specialty 44520 GSI Engineering, LLC INSURER C: 4105 W. 99th Street INSURERD: INSURER E: Carmel IN 46032 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1642144266 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. ILTR I TYPE OF INSURANCE INSD ISWVD I POLICY NUMBER (MMIDD/YYYY)I(MM/DD/YYYY)I LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ X68281 5/1/2016 5/1/2017 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY X jE LOC PRODUCTS-COMP/OP AGG I $ 3,000,000 OTHER: Employee Benefits I $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED X41879 5/1/2016 5/1/2017 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) Uninsured motorist BI split limit $ 1,000,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 EXCESS LIAR A CLAIMS-MADE AGGREGATE S 4,000,000 DED I I RETENTION$ X68281 5/1/2016 5/1/2017 $TH- WORKERS COMPENSATION X I STATUTE I 1 0TH AND EMPLOYERS'LIABILITY Y/N • ANY PROPRIETOR/PARTNER/EXECUTIVE NIA A E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? X41879 5/1/2016 5/1/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE - $ 1,000,000 If yes,describe under —--'DESCRIPTION-OF-OPERATIONS below - - - - - --- .- - - - - EL-DISEASE=POLICY LIMIT $ /000/000 -- B Professional Liability E&O PKC-103992 5/1/2016 5/1/2017 E&O/Pollution Occurrence 5,000,000 & Pollution Liability E&O/Pollution Aggregate 5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re: Performance Bond For: Contract Drilling Contract Amount: $41,200.00 MAY 6 2016 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salina THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O. Box 736 ACCORDANCE WITH THE POLICY PROVISIONS. Salina, KS 67402-0736 AUTHORIZED REPRESENTATIVE y�Q Paige Sexton/SFOUST ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)