Matzen COL.tif A W CERTIFICA L I NSURANCE 05/
I. �L � 7
PRODUCER THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION
State Farm Insurance - Joe Peleska, Agent ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1829 Washington St HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Blair, NE 68008 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
O INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: State Farm Fire and Casualty Company 25143 25143
MATZEN, TERRY INSURER B:
11174 RAMBLE RIDGE DR INSURER C:
BLAIR NE 68008 -7556 INSURER D:
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION
LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MMIDDIYY) DATE (MM /DDIYY) LIMITS
A GENERAL LIABILITY 97- BC- H400 -4 F 05/02/2011 05/02/2012 EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $
CLAIMS MADE E OCCUR MED EXP Any one person) $ 5, 00 0
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $ 2,000,000
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GENLAGGREGATELMITAPPUESPER PRODUCTS - COMPIOPAGG $
PRO -
X POLICY JECT LOC
{
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY
NON -OWNED AUTOS (Per accident) $
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY —EA ACCIDENT $
ANY AUTO OTHER THAN EAACC $
AUTO ONLY:
AGG $
A EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $
X OCCUR F] CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
X RETENTION $10,000 $
A WORKERS COMPENSATION AND WC STATU- O R
X TORY LIMITS ER
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 0
OFFICERIMEMBER EXCLUDED? 0
E.L DISEASE - EAEMPLOYEE $
If yes, describe under 0
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CONSTRUCTION
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _
CITY OF BLAIR 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
218 S 16TH ST FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
BLAIR NE 68008 INSURER, ITS AGENTS OR REPRESENTATIVE .
Fax: 402.426.4195 THORI E PRE ENTATIVE
e regls ra Ion notices indicate owners Ip o arK9 bylheir re pec v e
132849 03 -13 -2007 AI i hts reserved
l
Nov 0410 09:28a p.2
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DATE (MWDDIY"
.� CERTIFICATE OF LIABILITY INSURANCE 11/04/2010
i
PRODUCER THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION
State Fa-1 Insurance - Joe Peleska, Agent ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1829 Wash S- HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Blair, NE &8008 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
I
D INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURERA:State Faun: Fixe and CaSllaltY Company 25143 ,25143 j
MATZEN, TERRY INSURER B:
11174 RAMBLE RIDE DR INSURERC:
BLAIR NE 680 08 - 7 556 INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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 SUBJECTTOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
IN$R AW'L, POLICYEFFECTIVE POLICY EXPIRATION
LTR INSRD' TYPE: OF INSURANCE POLICYNUMBER DATE MM /DWYYI DATE MMIDDNYI LIMITS
GENERAL LIABILITY 97- BE — G163- -4 F C4f02/20_C' 04/02/2011 EACH OCCURRENCE 5 a- raQOr0QC
AMA RENT D
X COMMERCIAL GENERAL LIABILITY PREMISES jEa occurrence
CLAIMS MADE OCCUR MED EXP one ersm $ 5r 006'
PERSONAL &AOVINJURY $
GENERAL AGGREGATE $ 2
j GENLPGGIRECa0.MLWAPPLIESPER: PRODUCTS- COMPQPAGG $
PRO -
X POLICY JECT LOC
AUTOA90BILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANYAUTO
ALL OWNED AUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person)
I
HIREDAUTOS BODII- YINJIIRY $
(Per accident)
NON-O WNED AUTOS
PROPERTY DAMAGE
(Per accident)
GARAGE LIABILITY AUTO ONLY -- EAACCIDENT $
ANYAUTO OTHERTHAN EAACG $
AUTO ONLY: AGG
EXCESSJUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR L]CLAIMSMADE AGGREGATE $ 4-
3
DEDUCTIBLE I $
Ix RETENTION S10,000
$
A WORKERS COMPENSATION AND x TORY IM1TS ER
EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE E L. EACH ACCIDENT S 0
OFFICERIMEMBER EXCLUDED? 0
EL DISEASE - EAEMPLDYEE S
H yes, describe under 0
SPECVAL PROVISIONS below EL DISEASE - POLICY LIMIT $
OTHER
I
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CONSTRUCTION
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION j
CITY OF BLAIR DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _
218 S 16TH ST 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
BLAIR NE 68008 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
Fax: 402.426 INSURW ITS AGENTSOR REPRESENTATIVES,
AU D REP A E
ACOKD 25 (2001108) Th registration notices indicate owners Ip O s by thdir respective Owners WUUf
132849 03 -13 -2007 All rlghts reserved
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