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Insurance Certificate (Workers Compensation) ----1 ® A O o CERTIFICATE OF LIABILITY INSURANCE DA oMWDDf 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 CURT WAHLMEIER AMERICAN NAME' PHONE FAX PO BOX 130 (NC.No.Ed): (NC.No): E-MAIL ADDRESS: NORTON KS 676540130 78WK F INSURER(S)AFFORDING COVERAGE NAIC a INSURER A:TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA INSURED INSURER B: HURREN, JAMY & HURREN, INSURER C: MICHELLE DBA JMH CLEANING PO BOX 2985 INSURERD: - SALINA KS 67402-2985 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTEO CLAIMS-MADE El OCCUR PREMISES(Ea occurrence) S MED EXP(Any one person) 5 PERSONAL&ADV INJURY 5 GERIp_EA��GgqGREGATE LIMIT APPLIES PER: GENERAL S 'TWO PROJECT ❑LOCPRODUCTS-COMP/OP AGG 5 5 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) S —ANY AUTO BODILY INJURY(Per person) 5 —OWNED AUTOS —SCHEDULED BODILY INJURY(Per accident) 5 ONLY _AUTOS PROPERTY DAMAGE — HIRED AAUTOS NON-OWNED (Per accident) 5 AUTOS ONLY 5 UMBRELLA LIAB _OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE 5 DEDI RETENTION S S WORKERS CERS'LIAILIT PER OR A AND EMPLOYERS'LIABILITY (6JU8-0G25811-A-19) 09-28-19 09-28-20 X STATUTE I IOW- A ANY PROPRIETOR/PARTNERJD(ECUTNE OFFICER/MEMBER EXCLUDED? 111 YIN E.L.EACH ACCIDENT 5 1 .000,000 y (Mandatory in NH) l WA N E.L.DISEASE-EA EMPLOYEE(5 1.000.000 If yes,describe under 1 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S I.00,000 DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES(ACORD 101,Additional Remarks Schedule.may be attached if more space is required) LANDFILL FACILITY CERTIFICATE HOLDER CANCELLATION CITY OF SALINA MUNICIPAL SOLID SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE WASTE LANDFILL FACILITY POLICY PROVISIONS. 300 WASH ROOM 205 AUTHORIZED REPRESENTATIVE PO BOX 736 SALINA KS 67401 I I ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD (Rev.09-18) • A O CERTIFICATE OF'LIABILITYINSURANCE DA `MWDYY ,, , DATE 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 CURT WAHLMEIER AMERICAN PHONE FAX PO BOX 130 (AIC,No,Ext): (NC,No): E-MAIL ADDRESS: NORTON KS 676540130 INSURER(S)AFFORDING COVERAGE NAIC# 78WKF INSURER A:TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA INSURED INSURER B: HURREN, JAMY & HURREN, INSURER C: MICHELLE DBA JMH CLEANING PO BOX 2985 INSURER 0: SALINA KS 67402-2985 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ADOL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY))MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 DAMAGE TO RENTED CLAIMS-MADE El OCCUR PREMISES(Ea occurrence) S MED EXP(Any one person) 5 PERSONAL&ADV INJURY 5 GENgq ��L��AGGREGATE LIMIT APPLIES PER: GENERAL S P ltVIE PROJECT n LOC PRODUCTS-COMPIOP AGG 5 5 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) 5 — ANY AUTO BODILY INJURY(Per person) 5 —OWNED AUTOS —SCHEDULED BODILY INJURY(Per accident) 5 ONLY —AUTOS PROPERTY DAMAGE HIRED AUTOS NON-OWNED (Per accident) 5 AUTOS ONLY ,—AUTOS ONLY 5 — UMBRELLA LIAB _`OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE 5 DEDI IRETENTON 5 5 WORKERS COMPENSATION , PER OTH- A AND EMPLOYERS'LIABILITY (6JUB-0G25811-A-18) 09-28-18 09-28-19 STATUTE ER ANY PROPRIETORIPARTNER/EXECUNVE OFFICERIMEMBER ESCLUCED? YM EL EACH ACCIDENT 5 1,000,000i (Mandatory In NH) 1 y NIA N E L.DISEASE-EA EMPLOYEE$ I•000.000 If yes,describe under 1- DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S '1,000,000 DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION CITY OF SALINA MUNICIPAL SOLID SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE WASTE POLICY PROVISIONS. 300DWIAS FROIMI2Y AUTHORIZED REPRESENTATIVE 300 W ASH ROOM 205 PO BOX 736 SALINA KS 67401 I ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD (Rev.09.18)