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2011t � 1 �� p �I o``1J rise of a� March 4, 2011 Dan Williams Wild Willys Fireworks, LLC 7913 Hidden Valley Drive Papillion, NE 68046 RE: Firework License in Blair Dear Mr. Williams, The Josephs Coat Thrift Store & Food Pantry has been awarded two (2) licenses for fireworks in Blair for 2011. We have received your Certificate of Insurance but will need to receive your Nebraska State Fireworks Permit Licenses no later than June 15, 2011. Enclosed you will find a map indicating the location of the space that has been designated for your sales outlet at Vet's Field. As discussed, you may have one (1) -40 x 80 tent which will need to allow for setup of the tent along with storage of all trailers and trash containers to meet the minimum State Fire Marshal standards on setback requirements (Please see attached map for layout options and maximum tent size).You are also required to furnish trash service providing ample trash containers to handle your own trash accumulation. All trash related to firework business is required to be cleaned up daily. The City will provide one 110 volt, 15 amp outlet for each of the spaces. If you have any questions or need additional information, feel free to contact me. We look forward to working with you for a safe and profitable fireworks season. Sincerely, Brenda Wheeler City Clerk Enc Cc: Josephs Coat Thrift Store & Food Pantry, 1777 Washington St., Blair, NE 68008 Lei OPPORMITY 218 South 16th Street • Blair, Nebraska 68008 • 402 - 426 -4191 • Fax 402 - 426 -4195 • E -mail cityofblair @cLblalr,ne,us 5. Name of vendor participating with applicant (if applicable) ���, t �ty S fite l vs t 6. Address of vendor \ Jc��ev D i . Contact Person \4 ` � V t c,M s Phone # �C ` 7. Is certificate of insurance held by applicant or vendor? Vendor Applicant F-1 8. If held by vendor, does insurance name applicant and city as additional insurers? Yes 0 No F- � 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # co 1® c> t6l 33 - 71' (Name of Holder) 1r i `� `� 1r t sr�r I , y. L C Uwe, the authorized representative of the above applicant and/or vendor, do hereby make application for a fireworks license to be issued by and through the City of Blair, Nebraska. Uwe further agree to abide by all regulations and ordinances of the City of Blair Nebraska and State of Nebraska relative to this application and the sale and §�orage�eworks in the City of Blair, Nebraska. -- Date - s- A Date FOR CITY USE ONLY: Date Received Time Received Applicant awarded license: Yes El No F Vendor (if applicable) 1)"RAY INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 No. 130201 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. Admiral Insurance Company POLICY NO. CA000003209 -21 -1091 ��\���� "►_ it � ' i "i � ��� Wild Willy's Fireworks 7913 Hidden Valley Drive Papillion, NE 68046 March 1, 2011 to March 1, 2012; Both Days 12:01 A.M. Standard Time Premises - Operations Liability: [0 Occurrence Basis ❑ Claims Made Basis $1,000,000 each occurrence, $5,000,000 general aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. The sale of consumer fireworks (1.4G) and related products at the insured location, during the period of operation. It is certified that, if named below, this policy includes as Additional Insureds 1) the operator of the insured location used principally for the retail sale of the Named Insured's consumer fireworks and/or 2) the owner of the property on which the Insured location is situated and/or 3) the licensing authority issuing a permit or license for the insured location and/or 4) an entity for which coverage is required by written contract. l.a City of Blair 218 South 16th Street Blair, Nebraska 68008 Voice (402) 4264191 Joseph's Coat Thrift Store & Food Pantry 1737 Washington St. Blair, NE 68008 A DDR ESS M115 � l �F is Joseph's Coat Thrift Store & Food Pantry 1737 Washington St. Blair, NE 68008 PERIOD OF OPERATION June 23 2011— July 5 2011 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. March 1 S ` 2011 DATE OF ISSUE GER, PRESIDENT DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 No. 150101 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER Admiral Insurance Company POLICY NO. CA000003209 -21 -1091 NAMED INSURED Wild Willy's Fireworks 7913 Hidden Valley Drive Papillion, NE 68046 POLICY TERM March 1, 2011 to March 1, 2012; Both Days 12:01 A.M. Standard Time COVERAGE Products Liability, including broad form vendors liability: ® Occurrence Basis ❑ Claims Made Basis LBUT OF LIABILITY $2,000,000 each occurrence, $5,000,000 products aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured INSURED OPERATIONS The manufacture, sale or distribution of consumer fireworks (1.4G) and related products. It is certified that, if named below, this policy includes as Additional Insureds 1) the distributor of the Named Insured's products and/or 2) the owner of property on which the Named Insured's products are sold and/or 3) the licensing authority issuing a permit or license for the sale of the Named Insured's product and/or 4) an entity for which coverage is required by written contract. NAME(S) OF ADDITIONAL INSURED(S) City of Blair 218 South 16th Street Blair, Nebraska 68008 Voice (402) 426 -4191 Joseph's Coat Thrift Store & Food Pantry 1737 Washington St. Blair, NE 68008 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. DRAYTON INSURANCE BROKERS, INC. March 1 St 2011 DATE OF ISSUE . STRINGER, PRESIDE �-" up I ff-" 1 M 13 1 19 0M, 1 kri if M 1. 2. 3. 4. 5. Calendar Year for Application 2011 Name of Applicant j , ogee} 5 CDfty F Address of Applicant A5 Rx, M r Contact Person ( A4 ( e l b , � Phone # q02- 0 q `f D Is applicant working through a vendor? Yes F%K No ❑ Name of vendor participating with applicant (if applicable) Wilb JA r L S 'r 6. Address of vendor 7. 8. If held by vendor, does insurance name applicant and city as additional insurers? Yes 19 No ❑ 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # 001 (Name of Holder) Uwe, the authorized representative of the above applicant and/or vendor, do hereby make application for a fireworks license to be issued by and through the City of Blair, Nebraska. Uwe further agree to abide by all regulations and ordinances of the City of Blair Nebraska and State of Nebraska relative to this application and the sale and storage of fireworks in the City of Blair, Nebraska. - �"6 ° X0 - Date - 2 ® z3 °2o11 Date FOR CITY USE ONLY: Date Received Time Received Applicant awarded license: Yes ❑ No Contact Person Q W 4 S Phone # N 1 r Z 0 Is certificate of insurance held by applicant or vendor? Vendor Applicant INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALAB AMA 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 No. 130201 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. Admiral Insurance Company POLICY INTO. CA000003209 -21 -1091 Wild Willy's Fireworks 7913 Hidden Valley Drive Papillion, NE 68046 March 1, 2011 to March 1, 2012; Both Days 12:01 A.M. Standard Time Premises- Operations Liability: ® Occurrence Basis ❑ Claims Made Basis $1,000,000 each occurrence, $5,000,000 general aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. The sale of consumer fireworks (1.4G) and related products at the insured location, during the period of operation. It is certified that, if named below, this policy includes as Additional Insureds 1) the operator of the insured location used principally for the retail sale of the Named Insured's consumer fireworks and/or 2) the owner of the property on which the Insured location is situated and/or 3) the licensing authority issuing a permit or license for the insured location and/or 4) an entity for which coverage is required by written contract. NAME(S) OF DITIONAL INSURED(S) City of Blair 218 South 16th Street Blair, Nebraska 68008 Voice (402) 426 -4191 Joseph's Coat Thrift Store & Food Pantry 1737 Washington St. Blair, NE 68008 Joseph's Coat Thrift Store & Food Pantry 1737 Washington St. Blair, NE 68008 PERIOD OF OPERATION June 23 2011 — July 5 d ', 2011 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. March, 1 St 2011 DATE OF ISSUE GER, PRESIDENT 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA. 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 No. 150101 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER Admiral Insurance Company POLICY NO. CA000003209 -21 -1091 NAAND INSURED Wild Willy's Fireworks 7913 Hidden Valley Drive Papillion, NE 68046 POLICY TERM March 1, 2011 to March 1, 2012; Both Days 12:01 A.M. Standard Time COVERAGE Products Liability, including broad form vendors liability: ® Occurrence Basis ❑ Claims Made Basis LBUT OF Y $2,000,000 each occurrence, $5,000,000 products aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. INSURED OPERATIONS The manufacture, sale or distribution of consumer fireworks (1.4G) and related products. It is certified that, if named below, this policy includes as Additional Insureds 1) the distributor of the Named Insured's products and/or 2) the owner of property on which the Named Insured's products are sold and/or 3) the licensing authority issuing a permit or license for the sale of the Named Insured's product and/or 4) an entity for which coverage is required by written contract. NAME(S) OF DITIONAL INSURED(S) City of Blair 218 South 16th Street Blair, Nebraska 68008 Voice (402) 4264191 Joseph's Coat Thrift Store & Food Pantry 1737 Washington St. Blair, NE 68008 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured's), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. March, 1s 2011 DATE OF ISSUE A-IZINGER, P SIDE IN ,i O 4 1 �7i.cn March 4, 2011 Roger Burris Phantom Fireworks 2840 S. 70"' Street, Ste -7, PMB -149 Lincoln, Nebraska 68506 RE: Firework License in Blair Dear Mr. Burris, The Blair Eagles Aerie #3215 has been awarded one (1) license for fireworks in Blair for 201 We have received your Certificate of Insurance but will need to receive your Nebraska Sta Fireworks Permit License no later than June 15, 2011. Enclosed you will find a map indicating the location of the space that has been designated for your sales outlet at Vet's Field. Please remember that your tent will need to be siz e accordingly to allow for setup of the tent along with storage of all trailers and trash containers to meet the minimum State Fire Marshal standards on setback requirements (Please see atta map for layout options and maximum tent size).You are also required to furnish trash service providing ample trash containers to handle your own trash accumulation. All trash relat 15 firework business is required to be cleaned u daily. The City will provide one 110 v amp outlet for each of the spaces. If you have any questions or need additional information, feel free to contact me. We look forward to working with you for a safe and profitable fireworks season. Sincerely, Prend Whee er City Clerk Enc — (2) Cashier's Checks 270102566/270102567 Cc: Blair Eagles Aerie #3215, PO Box 242, Blair, NE 68008 EQUAL NOUSINO OPPORTUNITY 218 South 16th Street • Blair, Nebraska 68008 • 402 -426 -4191 • Fax 402 -426 -4195 E -mail cifyofblair @cLblair,ne,us APPLICATION FIREWORK LICENSE 1 Calendar Year for Application 2011 2. Name of Applicant - -(%,,F-7, F�In-'r r E- L L 3. Address of Applicant 1 2-q2- , r,- AL r ( C--: Contact Person Phone 4 � - 2- 4. Is applicant working through a vendor? Yes No ❑ 5. Name of vendor participating with applicant (if applicable) 6. Address of vendor PLA R 141 Contact Person Phone # 40 c-1 (-1. - - L 7. Is certificate of insurance held by applicant or vendor? Vendor Applicant 8. If held by vendor, does insurance name applicant and city as additional insurers? Yes V No � 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax# L-rl-(-'� M146 (Name ofHolde C, ,E- , ��,U M 5 Holder T,`1 1 1 V- &- y"i -e_ ::3 Uwe, the authorized representative of the above applicant and/or vendor, do hereby make application for a fireworks license to be issued by and through the City of Blair, Nebraska. Uwe further agree to abide by all regulations and ordinances of the Cit of Blair, Nebraska and State of Nebraska relative to this el - r application and the sale and storage offir T: `the , Z fiy �l e Applicant Date Vendor (if applicable) Date FOR CITY USE ONLY: Date Received Time Received Applicant awarded license: Yes 0 No - 0 / 1 ® CERTIF LIABIL I NSURANCE A / V DATE (MM /DD/YYYY) 02/21/2011 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 ALTERTHE COVERAGE AFFORDED BYTHE 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 MCGRIFF, SEIBELS & WILLIAMS INC. P.O. Box 10265 CONTACT NAME: PH A/C No Ext : 800- 476 -2211 A/ , No): E -MAIL ADDRESS: Birmingham, AL 35202 INSURER(S) AFFORDING COVERAGE NAIC # EGLB01888932 INSURER A :Liberty Surplus Insurance Corporation 10725 EACH OCCURRENCE INSURED B J Alan Company INSURER B dronshore Specialty Insurance Company 25445 Big Bear Fireworks, Inc. INSURER C: Phantom Fireworks, Inc. 555 Martin Luther King, Jr. Blvd INSURER D ; INSURER E : Youngstown, OH 44502 INSURER F: COVERAGES CERTIFICATE NUMBER :NPPWV9S5 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DD/YYYY LIMITS A GENERAL LIABILITY EGLB01888932 10/30/2010 10/30/2011 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 CLAIMS -MADE F_x1 OCCUR MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY JECT PRO - X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED AUTOS NON -OWNED AUTOS B UMBRELLA LIAB X OCCUR 000770201 10/30/2010 10/30/2011 EACH OCCURRENCE $ 9,000,000 X AGGREGATE $ 9,000,000 EXCESS LIAR CLAIMS -MADE DED I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N WC STATU- OTH- TORY LIMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? a N/A (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 space is required) This certificate relates to the operations of Phantom, of Nebraska, Inc. at 2840 S 70th St., Ste 7, PMB 149 Lincoln, NE. 68506; Blair Vets Field 1301 Butler Street Blair NE 68008; Blair Eagles Aerie #3215 PO Box 242 Blair NE 68008 The above listed are Additional Insured respects to General Liability policy as required by written contract subject to policy terms, conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATETHEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Blair Brenda Wheeler AUTHORIZED REPRESENTATIVE 218 S 16th Street d a , Blair, NE 68008 ,. h ' Rfl . �S. 1 Page 1 of 1 ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD NE ST R M A t S ou th 1 St reet 9 Linc 68 50 8 - 1 8 04 LICENSE F SALE OF FIREWORKS JULY 0 Permissible fireworks may be sold at retail commencing 12:01 AM June 25 and ending 11:59 PM July 4 and must be purchased from a licensed distributor or jobber. A jobber may not sell retail. Invoice copies for all fireworks must be kept available for inspection and must show the license number of the distributor or jobber. Fireworks may not be sold outside the city limits of an incorporated town or village. Violations of State Fire Marshal regulations may result in immediate revocation of this license. Rules and regulations can be viewed and printed from our website: www.sfm.ne.gov. LICENSE GOOD ONLY FOR JUNE 25 - JULY 4 OF YEAR LICENSE ISSUED This copy signed, dated and numbered by the STATE FIRE MARSHAL constitutes issuance of a LICENSE pursuant to the provisions of Nebraska Revised Statute 28 -1246 (1994 Supp.). Such license shall be displayed at licensee's place of business. DATE RECEIVED: 3/1/2011 TYPE OF LICENSE AND FEE: RETAILER $213.00 0 a Stand #: 2011 -RP- 788128 - 1195 -RL -002 1301 BUTLER ST BLAIR STORAGE LOCATION: 1301 BUTLER ST BLAIR DISTRIBUTORS) /JOBBER(S): BJ ALAN COMPANY SALES TAX NUMBER: 17700474 PHANTOM OF NEBRASKA INC 2840 S 70TH ST STE 7 PMB 149 LINCOLN NE 68506- WASHINGTON WASHINGTON J �l 3/1/2011 STATE FIRE MARSHAL LICENSE NUMBER I P-11 DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 TELEPHONE: (205) 854 -5806 FAX: (205) 854 -5899 NO. 130201 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER NAMED INSURED POLICY TERM COVERAGE LIMIT OF LIABILITY INSURED OPERATIONS Admiral Insurance Company POLICY NO. CA000003209 -21 -1091 Wild Willy's Fireworks 7913 Hidden Valley Drive Papillion, NE 68046 March 1, 2011 to March 1, 2012; Both Days 12:01 A.M. Standard Time Premises - Operations Liability: ® Occurrence Basis ❑ Claims Made Basis $1,000,000 each occurrence, $5,000,000 general aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. The sale of consumer fireworks (1.4G) and related products at the insured location, during the period of operation. It is certified that, if named below, this policy includes as Additional Insureds 1) the operator of the insured location used principally for the retail sale of the Named Insured's consumer fireworks and /or 2) the owner of the property on which the Insured location is situated and /or 3) the licensing authority issuing a permit or license for the insured location and /or 4) an entity for which coverage is required by written contract. NAME(S) OF ADDITIONAL INSURED(S) City of Blair 218 South 16 Street Blair, Nebraska 68008 Voice (402) 426 -4191 Joseph's Coat Thrift Store & Food Pantry 1737 Washington St. Blair, NE 68008 ADDRESS OF INSURED LOCATION Veterans Memorial Ball Field Blair, NE 68008 PERIOD OF OPERATION June 23r 2011— July 6 2011 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and /or the undersigned. DRAYTON INSURANCE BROKERS, INC. March 1 St 2011 DATE OF ISSUE A RINGER, PRESIDENT