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DATE(MM/DDNM)
nii CERTIFICATE LIABILITY 10/29/2015
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:Ifthe certificate-ktolder-is.an.ADDITIONAL INS_URED,.the policy(ies).miust be endorsed.-If.S.UEROGATION.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
M&H INSURANCE AGENCY INC NAME`
3020 U1 OODBURY DR PHQNN
FAX
i AlC,Na,Ext:
SAINT PAUL, MN. 55129 A DRESS;
Phone:651-731-8268 Fax:651-731-4665 INSURERS AFFORDING COVERAGE NAIL#
14184
INSURER At ACUFTY
INSURED INSURER 81
MAGI S LLC INSURER C:
3013 13TH TER NW INSURERD:
NEW BRIGHTON., MN. 5511-2 INSUREREi
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.
INGR ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/ODIYYYY) M/DDNYYY LIMITS
A COMMERCIAL-GENERAL LIABILITY EAGH-OCCURRENCE $1;0001,000
CLAIMS MADE OCCUR DAMAGE TO RENTED $100,000
PREMISES(Ea acr�rencel
X Bls-Pak Business Liability and Medical MED EXP(Any one person) $5,000
Expenses CBX79901 09/18/2015 09/18/2016
PERSONAL&ADV INJURY Inicluded
GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
PRO- PRODUCTS-COMPIOP AGG $2,000,000
POLICY EDJECT 1:1 LOC
OTHER: 4 $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NDN-OWNED PROPERTY DAMAGE �
HIRED AUTOS AUTOS (Per accident)
UMBRELLA LIABOCCUR EACH OCCURRENCE $
EXCESS LIAB HCLAIMS-MADE AGGREGATE $
DED RETENTION $ S
WORKERS COMPENSATION AND PER OTHER
STATUTE
EMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNER/ NIA' E.L'EACH ACCIDENT $
EXECUTIVE OFFICER/
MEMBER EXCLUDED? E.L.DISEASE EA EMPLOYEE $
Ityes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES
------- - ---- ---- --- --- - --- -------------- -----
CERTIFICATE HOLDER CANCELLATION
City Of Blair SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
ATTN;Contractor Registration DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY
-218 South 16th-Street PROVISIONS.
Blair, NE. 68008
AUTHORIZED REPRESENTATIVE
OO 1988-2014 ACORD-CORPORATION. All-rights-reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
CL-517(1-14)
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