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Travis COLCERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 11 /03/2023 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 JOE PELESKA MF Statelrl JOE PELESKA- STATE FARM AGENT 1829 WASHINGTON ST `"' BLAIR NE 68008 aCNNo Ext : 402-426-2320 Nc No : 402 426-5060 E-MAIL INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: State Farm Mutual Automobile Insurance Company 25178 INSURED INSURER B : INSURERC: TRAVIS MANN INSURER D : 1449 VOSS DR INSURERE: BLAIR NE 68008 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 LTR TYPE OF INSURANCE ADD NSD SUB WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR 27-BG-5148-2 03/14/2023 03/14/2024 EACH OCCURRENCE $ 1,000,000 TED DREM SESAGE � a occurrence) a ce $ MED EXP (Any one person) $ 1,000 PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO POLICY JECT LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED r NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ Per accident $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? r (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N I A PER OTH- $ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) LOCATION 1006 STATE ST BLAIRNE 68008DWELLING UNDERCONSTRUCTION OWNER ACTING AS GENERAL CONTRACTOR CFRTIFICATF HOI_nFR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF BLAIR ACCORDANCE WITH THE POLICY&PELEM Z/*-�oG 218 S 16TH ST AUTHO ID REPRESENTATIVE BLAIR NE 68008 RURAL NEBRASKA TWO F187 v ©1988-2bt"CORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.14 04-13-2022