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i ® DATE (MM /DD/YYYY) A ° CERTIFICATE OF LIABILITY INSURANCE 10/2/2012 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 CONTACT BLAIR Insrance A en NAME: u g Blair Insurance Agency PHONE (402) 426-4888 A/C No: (402)426 -4875 1529 Lincoln a Ole .bia @washingtoncountybank.com INSURERS AFFORDING COVERAGE NAIC # Blair NE 68008 INSURERA:Nationwide Mutual Ins Cc 23787 INSURED - INSURERS: ANDERSEN, DONALD E INSURERC: 107 N OSBORN AVE INSURERD: INSURER E : OAKLAND NE 68045 -1221 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1210215241 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 LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY I (MM/DD/YYYY1 LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,000 DAMAGE TO RENTE X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occur ence ) $ 100,000 A CLAIMS -MADE a OCCUR &CP7234011508 5/4/2012 5/4/2013 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 I GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OPAGG $ 1,000,000 NO POLICY PRO- LOC $ I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO _ BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY y / N ER ANY PROPRIETOR/PARTNER /EXECUTIVE F-1 NIA E.L. EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ yes, describe under D E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER, CANCELLATION I ( 402) 426 -4195 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 S. 16th Street Blair, NE 68008 AUTHORIZED REPRESENTATIVE K Howard LWARREE ACORD 25 (2010105) ©1988 -2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD