ArkC COL.tif I
JUL -15 -2014 14:03 FROM:HOFFMAN AGENCY 712- 642 -4171 TO:14024264195 P.1 E
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✓"� DATE (MMIDDIYYYY)
AC(::)R-" CERTIFICATE OF LIABILITY INSURANCE 7/15/2Ot4
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(les) must be endorsed. If SUBROGATION 13 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 o f such endorsement(s).
PRODUCER Pllonc: 7121642-2262 NAME: C Missouri Valley Offioo
Fax: 7123642-4171 PHONE 712 - 642 -2262 FAx 712- 642.4171
The Hoffman Agency ac NP
1 N 5th AciDRlESS: hoffmanMVQgwestof ce.nct
Missouri Valley, 1A 51555 INSURERS AFFORDING COVERAGE NAIC
INSUR A: National Mutual Insurance Co mpany 20184
INSURED INSURERS:
Johnnie King DBA: Ark Construction INSURERC:
411 E Martin St INSURER D
Modale, lA 51556
INSURER fi
INSURER F
COVERAGES CERTIFICATE NUMBER: 9 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.
PDLley EFF POLICY EXP
1L TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MM! D LIMITS
A �/ COMMERCIAL GENERAL LIABILITY 7165279 -0 7 7/9/2015 EACH OCCURRENCE $ 1 ,000,000
CLAIMS.MADE F OCCUR PREMISES 156 opw ge $ 5
MED EXP (Any one rson) $ '
Pe
PERS0t4AL A ADV INJURY 3 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
POLICY P a LOC PRODUCTS - COMP /OP AGG $ 2 ,000,00 0
OTHER:
AUTOMOBILE LIABILITY Ea acold
e jSIN LE LiMI $
ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY (Peraeddent) $
AUTOS AUTOS ONED PROPERTY DAMAGa
Per a d
HIRED AUTOS AUTOS $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS -MADE AGGREGATE $
OECD) RETENTION $ _ $
WORKERS COMPENSATION STA LltE ETH
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNE:R1@XECUTIVE �"1 NIA E.L, EA ACCIDENT $_..
OFFICERIMEMBER EXCLUDED? u E.L. DISEASE - EA EMPLOYE: $
(Mandatory In NH)
If yes, describe under. El. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addiilonal Remarks Schsdul$, may be attached If more space is required)
CERTIFICATE HOLDER CANCELLATION
Certificate Holder 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 PROVISIONS.
I
218 S 16th Street c
Blair, NE 68008 ( AUTHORIZED REPRESEN Ti
0 9 - 14 ACOIRID CORPORA N. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are reglst ed mar of ACORD