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Insurance ____—....,4 SAMYOCL-01 SDONNELLEY J4 RO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD YYYY) �� 3/23/2021 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: Insurance Center,Inc.(ICI) PHONEFAX 120 W. Central Ave. (ac,No,Ext):(316)321-5600 1(A/C,No):(316)321-5625 El Dorado,KS 67042-2138 Pim,DAIIIE s s,ici@ici.insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:EMCASCO Insurance Company 21407 INSURED INSURER B:EMPLOYERS MUTUAL CASUALTY COMPANY 21415 Samy's OC LLC INSURER C:First Dakota Indemnity Company 10351 1911 E Kansas Ave INSURER D: Garden City,KS 67846 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 TYPE OF INSURANCE ADDL SUBR WPOLICY NUMBER /YPOLICY EFF POLICY EXP LIMITS LTR INSD VD IMM/DDYYYI _(MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ $ 1,000,000 CLAIMS-MADE X OCCUR 6X18365 3/30/2021 3/30/2022 DAMAGE TO RENTED 1,000,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY- $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ypei LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ COMBIED B AUTOMOBILE LIABILITY Ea accident SINGLE LIMIT $ 1,000,000 X ANY AUTO 6X18365 3/30/2021 3/30/2022 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOSppBODILY INJURY(Per accident) $ AUTOS ONLY _ AUUTOS ONLYY PROPERTY DAMAGE (Per accident) $ $ B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE 6X18365 3/30/2021 3/30/2022 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ C WORKERS COMPENSATION X I STATUTE I I ERH AND EMPLOYERS'LIABILITY YN WCO20-0049504-2021A 3/31/2021 3/31/2022 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE YN/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ A Liquor Liability 6X18365 3/30/2021 3/30/2022 Each Common Cause 1,000,000 A Liquor Liability 6X18365 3/30/2021 3/30/2022 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Amro Samy is excluded on the Workers Compensation policy. :The City of Salina is an additional insured on the General Liability policy as required by written contract subject to policy terms and conditions. CERTIFICATE HOLDER CANCELLATION 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. PO Box 736 Salina,KS 67402 - AUTHORIZED REPRESENTATIVE f ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD