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Matthew COL.tif I AC®® CER TIFICATE DATE (MMIDDIYYYY) LI I NSURANCE 9/17/2013 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 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). CONTACT Teri Gernstein PRODUCER NAME: Peterson Brothers Insurance, Inc. = Extj (402) 330 -2048 F AIC No: (402) 330 -9561 13939 Gold Circle #200 AD MD R IESS: teri @petersonbrothersinsurance.com INSURERS AFFORDING COVERAGE NAIC # Omaha NE 68144 -2359 INSURERA-ACUitY 14184 INSURED INSURER B: Block Construction Group LLC% INSURERC: C/O Matt Block INSURER D : 8510 BURT ST INSURER E : OMAHA NE 68114 INSURER F . COVERAGES CERTIFICATE NUMBER:2013 - 20 14 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 SUBR POLICY EFF POLICY EXP LIMITS "R TYPE OF INSURANCE IN ZLYD POLICY NUMBER (MM/DDIYYYY1 IMMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED � X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 A CLAIMS -MADE ® OCCUR K66973 /12/2013 /12/2014 MED EXP (Any one person) $ 5,000 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2,000,000 X $ POLICY PRO LOC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident i UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION WC STATU- OE H- AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER/EXECUTIVE YIN E.L. EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION cityofblair@ci.blair 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 So. 16th St. AUTHORIZED REPRESENTATIVE Blair, NE 68008 -2010 Teresa L. Gernstein ACORD 25 (2010105) ©1988 -2010 ACORD CORPORATION. All rights reserved. INS®25ronlnn.m n9 Tha Ar OPn nama anrt Innn ara raniatararl mnrirc of Arnpn