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Madsky COL.tif 0: Pa e 2 of 2 2014 -10 -14 15:31:35 (GMT) 18555244009 From: Jim Kirk i Policy Number: Date Entered: 10/13/2014 ac® ®® CERTIFICATE OF LIABILITY INSURANCE DATE(MrwDDNYYY) 10/13/2014 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). PRODUCER NAME: Bobble Ja=z Bell -Scott Insurance Group Dub- Lafayette /Roofers Choice Insurance Nc N No EXt: (855) 766 -3980 a/c No): (877) 937 -7521 MAIL bbble s @b -i com ADDRESS: o g- P.O. BOX INSURER(S) AFFORDING COVERAGE NAIC 4 Waxx ahachie, , T Tx x 75168 INS UREA A: ("ae1ri1111 Insurance Company 10833 INSURED INSURERS; Endurance American Speciality Ins. MadSky Roofing and Restoration, LLC INS URERC; 11030 Circle Point Road, Suite #425 INSURER D: Westminster, CO 80020 INSURER E; 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. INSR ADDLSUBR POLICYEFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MRNDD/YYYY MNVDD /YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $1 A &I COMMERCIAL GENERAL LIABILITY VGGPOO1355 10/24/2014 10/24/2015 PREMISES Ea occurrence $ 50,000 CLAIMS -MADE OCCUR MED EXP (Any one person) $ Excluded T7: PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: PRODUCTS - COMPIOP AGG $2 POLJ CY PE0. LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $1,000,000 A ANYAUTO VGGPOO1355 10/24/2014 10/24/2015 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ B UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS -MADE E %C10004303501 10/24/2014 10/24/2015 AGGREGATE $1,000 DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR /PARTNER/EXECUTIVE L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N!A E (Mandatory in NH) E.L. DISEASE -EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101,Additional Remarks Schedule, if more spaceis required) I I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Blair - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 218 S. 16th Street ACCORDANCE WITH THE POLICY PROVISIONS. Blair, NE: 68008 AUTHORIZED REPRESENTATIVE Jack Scott © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Producedusing Forms Boss Plus software www. FormsBoss .comlmpressivePublishing 800 - 208 -1977