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PrairieC Registration 2024CITY OF BLAIR 218 S 161h Street Blair, NE 68008 (402) 426-4191 Fax (402) 426-4195 Email: building@blairnebraska.org FOR OFFICE USE ONLY Date Paid: --I � l Receipt No: i, Check # or CC: S Amount Paid: d CONTRACTOR REGISTRATION / LICENSE RENEWAL PRAIRIE CONSTRUCTION Please verify and correct the company / brisiness 13316 B ST Information listed here: OAMAHA NE 68144 Type of Business: CONTRACTOR LICENSE Contact information on record: Type: Phone Number: Type: Phone Number: Work 402 330-8522 Fax 402 330-8544 Cell Email Address: MATT PRAIRIE-CONSTRUCTION.COM Please submit a current reciprocating license for those which will or have expired:• Name: Reciprocating License: Expires: Please submit new certificates or bond renewals and NDOL for those which will or have expired..• Name: Certificate of Liability or Bond: Expires: PRAIRIE CONSTRUCTION GENERAL 1/01/2024 PRAIRIE CONSTRUCTION NDOL 10/01/2023 Place a check in the box next to the licenses you Tvish to renew, Rene ? Name: License / Registration: Expires: Amount: PRAIRIE CONSTRUCTION CONTRACTOR LICENSE 1/01/2024 60.00 Pay this amount: 60.00 Please list any additional licenses or registrations: Name: I License / Registration: Amount: I hereby make an application to the Licensing Board of Blair, Nebraska and certify, that I am competent and experienced to engage in the above said vocation. I agree to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said vocation and obey all orders, requirements, and regulations of its lawful constituted authorities. I also certify that all information contained in this application is true and correct. I will notify the City of Blair of any changes in the information reported on or with this application form within 15 days.of any change. IZ�z AuthoriAe Sig ature Date Contractor Details Contractor/Subcontractor Name PRAIRIE CONSTRUCTION COMPANY Corporation Name PRAIRIE CONSTRUCTION COMPANY Business Entity S-Corporation Address 13316 B STREET OMAHA, NE 68144-3612 City OMAHA State NE Zip 68144-3612 Telephone (402) 330-8522 Registration Number 21811-23 Registration Expiration 10/1/2024 Sales Tax Option 2 Number of Employees 30 Worker's Compensation Status Certificate on File ACC,O0RDO CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/29/2023 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 Hub International Great Plains LLC 11516 Miracle Hills Drive Suite 100 CONTACT NAME: Travis Nelson PHONE FAX s0o-288-5501 AlC No): 402-964-5454 ADDRESS: Travis. Nelson@hubinternational.com INSURERS AFFORDING COVERAGE NAIC # Omaha NE 68154 INSURER A: Zurich American Insurance Company 16535 INSURED PRAICON-04 INSURER B: American Guarantee & Liability Insurance Company 26247 Prairie Construction Company 13316 B Street INSURER C INSURER D : Omaha NE 68144-3612 INSURER E : INSURER F : rnVFRAnPR CFRTIFICATF N►IMRFIR 13R33d773A 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 ADDL SUBR POLICY NUMBER POLICY POLICY M/D �YY XP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE1�1 OCCUR GLO 8659090 - 00 1/1/2024 1/1/2025 EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED PREM SESOEa ocur enca $ 500,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECOT- LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGO $2,000,000 $ A AUTOMOBILE LIABILITY IX ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY BAP 8629031 - 00 1/1/2024 1/1/2025 COMBINED SINGLE LIMIT Ea accldenl $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ B X UMBRELLA LIAR EXCESS LIAB X OCCUR CLAIMS -MADE SXS 8659089 - 00 1/1/2024 1/1/2025 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DED I X I RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC 8659091 - 00 1/1/2024 1/1/2025 X STATUTE DTH ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500.000 Ej A Contractors Equipment CPP 8664458-00 1/1/2024 1/1/2025 Scheduled Equippment Leased/Rented Equlp $550,000 $100,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if morn space is required) 1'F0TI9:IL`ATG Wr)I nr-O CANCFI I ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Blair 218 S 16th St Blair NE 68008 AUTHORIZED REPRESENTATIVE © 19BB-2015 AGUKU GUKYUKA I IUN. An rign[s reservea. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD