2014v�
a
March 5, 2014
Eric Clauson
Wild Willy's Fireworks, LLC
1710 S. Hwy 50
Springfield, NE 68059
RE: Firework License in Blair
Dear Mr. Clauson,
The Josephs Coat Thrift Store has been awarded one (1) license for fireworks in Blair for 2014.
We received a Certificate of Insurance with your application which expired March 1, 2014.
Please submit a current certificate as well as your Nebraska State Fireworks Permit License by
June 16, 2014.
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 sized
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 attached
map for layout options and maximum tent size).You are also required to furnish trash service
providing a trash container no larger than six (6) yards to handle your own trash accumulation
(see attached map for trash storage). All trash related to firework business is requ ired to be
cleaned uu 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,
6 t�
Brenda Wheeler
City Clerk
Cc: Josephs Coat Thrift Store, 1737 Washington St., Blair, NE 68008
218 South 16th Street • Blair, Nebraska 68008 • 402 - 426 -4191 ^ Fax 402 - 426 -4195 • E -mail ciiyofblair @ci.blair.ne.us
If held by vendor, does insurance name applicant and city as additional insurers'?
IV El
Yes No
9 License fee - $5,000 (Attached)
l d1 Certificate of Insurance (Attached)
]I. Sales Tax QPA- arne of Holder) \AJ S-F�- L
-4 --LL
IA% c, the authorized reprtsentafi% e 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, Niebraska. Vue further agrev to abide by
all reLmlations ajid ordinances of the City of Blair, Nebraska and Staic of Nebraska relativc to thj
application and the sale and storage Of fiRAVOIkS in the City ot'Blair, Nebraska.
Date
-. -4
Date
FOR CITY 1 S ONTLY:
Date Received 3 1 � 11 Time Received
\r7f
Applicant awarded license Ye N, -, 0
NEBRASKA STATE FIRE L
246 South 14th Street
Lincoln, NE 68508 -1804
LICENS-EFOR SALE OF FIREWORKS
Permissible fireworks may be sold at retail commencing 12:01 AM June 25 and ending 11:59 PM July 4 OR 12:01 AM
December 29 and ending 11:59 PM December 31 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,
E ONLY FOR CALENDDAR YEAR 9' 'WHICH it'
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.:
April 17, 2014 11 :13 AM
TYPE OF LICENSE AND FEE:
Retail Permit (July) - $25.00
LOCATION OF OUTLET FOR RETAIL SALE OF FIREWORKS:
1301 Butler Street - Vets Ball Field
COUNTY:
Blair
Washington
Tent in parking lot
STORAGE LOCATION ::
DISTRIBUTORS) /JOBBER(S):
Wild Willy's Fireworks, LLC (2014 -RP- 6700480 -4)
SALES TAX NUMBER:
DATE ISSUED:
April 16, 2014 12`.04 PM
STATE FIRE MARSHAL
LICENSE HOLDER:
Joseph's Coat Thrift Store
LICENSE NUMBER:
2014 -RP- 7647164- 142 -01
0 CENTER ER POINT ROAD, SLITITE
BIRMINGHAIM, ALABAMA 35215
TELEPHONE: (203) 854 -5806
DRAYTCAN INSURANCE
301
POST OFFICE BOX 94067
BIRt1INGHA AL ABAbIA 3_i220
FAX: (203) 854 -5899
CERTIFICATE OF INSURANCE
No, 416222
tl e ccrtiti that insurance is afforded as stated below. This Certificate does not aliirmaticely or negatikeIN amend, emend or alter the coverage
afforded by the insurance policy and the inSLa'rnce uffordcd is stthiect to all the terms, eviusions and conditions ofthe policy.
INSURER Admiral Insurance C!ompam POLICY NO, C;'A000003209 24 -1091
NAMED INSURED Wild Willy's tiret\orks, 1.1:C'
1710- S. 11u G 50
Springfield: NF 68 )059
POLICY TERN] Nlavch 1. 2014 to'klarch 1. 2015: Bosh I)av 12:01 A.M. Standard "hire
COVERAGE Products t iahility. inCiudim, broad Iorm vendors liabiflw , OCCUrrence Basis 0 Claims Made Basis
LIMIT OF LIABILITY S2..000.000 each occurren c. 55.000.0()0 products a{ rc?ttte
The limit «1` liability shall not he increased by the inclusion of more than one insured or additional insured.
INSURED OPERATIONS iTe man it fact tire, sale or distribution of consumer Iire\\orks (1.44) and related products.
It is certified that, if reamed below, this policy includes as Additional Insureds 1) the distributor of the Named InSUred's products and/or 2) the
omier(s) manager(s), tenant(s), mortgagee(s) (includin_ other entities Iran in similar interests). of the property on \t tick the Insured Premises is
located and/or 3) the licensinio authority kl Uinla a pcn»it or license for the operation ofthc lnstircd Premises nncVor4) any entity for NNhich the
Named Insured is required, b� "rinen contract, to prov ide instiraaca such as is af'f'orded by the terms of this policy.
NANIE(S) OF
ADDITIONAL INSURED(S)
Citti of 131air
218 SOLAII W1 Street
Blair. Nebraska 611008
Voice (402) I26 -4191
Joseph's Coat'I'hrift Store d. hood Pantry
1737 Washinuton St.
Blair. \F: 6861 — h
It is certified that this policy requires a 30 da mutual notice of vancelltitio hemeen the Insurer and the gamed Insured. In the event of such
cancellation tike tt ill endeaurr to (trail 10 days mitten notice to the Additional In- mired(s). Miosc name and address is shml n hereon. but 1ailure
to mail such notice shall impose no obligation or liability ofam kind Upon the insurer and/or the undersigned,
DRAA TON INSURANCE BROKERS, INC.
m
April 1 8 "'. 2014
DATE OF ISSUE S "I`I2CNGEf2, PRESID)EN
D
2500 CENTER J'OIN'T ROAD, SUITE 301
BIRI IINGHAIM, ALABAMA 35215
TELEPHONE: (205) 854 -5800
YTON INSURANCE BROKERS, INC.
CFR TIF'IC'ATE OF INSURANCE
;T OFFICE BOX 94067
c)HANI, ALABAMA 35220
FAXi (203) 854 -5899
\t). 421322
4'vc certik that insurance is afforded as stated belov., This CertificUte d0Qs not allirnatiueh or ncp dvol lv amend. extend or alter the coverallc
afforded by the hisurance policy and the insurance af is subject to all the t=erry. cr,elusions and conditions of the I)olicy.
INSURER
NAMED INSURED
POLICCV TERtiI
COVERA
Admiral Insurance Company'
w`iki Willv's Fireworks, LEC'
171o5 S, Hov 50
Sprinofield. NE 68059
March 1, 2014 to vlarch 1. 2(j
Premise's-operations Liabilit)
POLICY \O. C'A000003209- 24-1001
15, 13011) Days 12 :01 .1AJ, Standard Fime
0 OCCUrrence Basis E) Claims Made Basis
LIMIT OF LIABILITY SI,O()t)MOO each occurrencC, `~5,000 gmie'ral a <agreg ite
ThC limit ofiiabiiit) shail not be increased b} the iatclusion of* more thall one insured or additional insured.
INSURED OPERATIONS The sale pfconsumer lirev +arks ( IAG) and related products at the Insured location. during, file period ofgperation.
It is certified that, for the period of operation stated below and when named below as such, this policy- includes as Additional Insureds 1) the
operator(s), sponsor(s). protnoter(s), organizer(s). of the Insured Premises used principralh for the retail stale of the Named InsureWs Consumer
Iiri. works and /or 2) tine ma ner(s), mrallager(s). tenant(s) moats"agee(s) ('including Either erriitius hoeing similar interest of the propert tan �tlaich the
Insured Premises is located andfar 3) the hCensing vuthorih issuing a permit or license for the operatiotn ai'the Insured Premises and/ 1 4) au;
Cntit) tor which the Named Insured i, t'erluirv(I. by �Fritten contract- to prov i& Ir,)stiraaice such as is afforded b) the term. ol`this policy.
iN'AAIE (S) OF
ADDITIONAL INSURED(S)
City of Blair
215 South 16° Street
Blair, Nebraska 68008
Voice (402)) 426 -4191
Joseph's Coat 'Thrift Store & Food Pantry
1737 Washimaon St.
Blair, NE 68008
ADDRESS OF
INSURED LOCATION
Veterans Memorial Bali Field
Blair. NE 65008
PERIOD OF OPERATION
Jtttte ?4 — July 5 "'. 2iJ 14
It is certified that this policy requh a 30 dray ntu(ua) notice of eancellation beu�een the losorer and the N'ttnted ltisure(l. ]n The event of such
cancellation we will endemor to mail if doe's arittcn notice to doe Additional htsured(s), Whose name and address Tess is shomi heron. but failure
to uaail aiich notice shall hnpose no obligation or iiabilit} of any kind upon the insurer anai.'or the ttndersi,med.
DRAYTON INSURANCE BROKERS, INC.
ApHI 1 8"'. 2014 —
DATE OF ISSUE A .. TPl \(aER,� PR - S177E,T
March 5, 2014
Rich Ludvik
Ka- Boomers Enterprises, Inc.
PO Box 86
Wahoo, NE 68066
RE Firework License in Blair
RY
Dear Rich,
1 license for fireworks in Blair for
The Trinity Lutheran Youth Group has been awarded one ( )
2014. please submit a current Certificate of Insurance as well as your Nebraska State Fireworks
Permit License by June 16, 2014.
Enclosed you will find a map indicating the location of the sp lb need t gbeed dr
your sales outlet at Vet's Field. Please remember that yo ur tent will
accrdin 1 to allow for setup of the tent along with sto reluirelments (Please see attached
� --�
meet the minimum State Fire Marshal standards on setback to furnish trash service
l ayou t options and m e u r ash accumulation
maximum tent size).You are also own t
map for y P ards to hand y
providing a trash container no larger than six (6) y
(see att
ached map for trash storage). All trash relate to fir o u tlet for each of the spac a
d to be
cleaned up daily. The City will provide one 110 volt, 15 amp
uestions or need additional information, fee to contact me. We look
If you hav e any q
forward to working with you for a safe and profitable fireworks s eason
Sincerely,
&UC
Brenda Wheeler
City Clerk
Cc: Trinity Lutheran Youth Group, 141 S. 20 St., Blair, NE 68008
• 402 - 426 -4191 • Fax 402 - 426 -4195 • E -mail cityofblair @cl.blalr.ne.us
218 South 16th Street •Blair, Nebraska 68008
1. Calendar Year for Application 2014
2. Name of Applicant Trinity Luthern Youth Group
3. Address of Applicant 141 South 20th Blair, NE 68008
Contact Person _ Dale Miller Phone# 402 -237 -9997
4. is applicant working through a vendor? Yes ® No ❑
5. Name of vendor participating with applicant (if applicable)
Ka- Boomer's Enterprises. Inc.
6. Address of vendor Po Box 86 Wahoo, NE 68066
847 Highway 77 Wahoo, NE 68066
Contact Person Rich Ludvik Phone# 402 - 443 -4593
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 No ❑
9. License fee - $5,000 (Attached)
10. Certificate of Insurance (Attached)
11. Sales Tax# 15671981 (Name of Holder) Ka- Boomer's Enterprises, I nc.
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.
FOR CITY USE ONLY:
Date Received Time Received
Applicant awarded license: Yes ❑ No 0
DATEiMMtDDlYYYY)
CERTIFICA LIABILITY U 3t141 2014 CIE
TS ON THE CERTIFIFATE - 14OLDER- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION O �N Y A ND OR ALTER COVERA u AF AFFORDED D B )
COES NO C OR1 E
CERTII ICATE T AFFIRMATIVELY OR N DOES NOT
BELOW. THIS CERTIFICATE OF INSURANE DT CONSTITUTE A CONTRACT BETWE EN THE I5
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
fre an endorsement. A statement ficate does not confer rights to the
IMPORTANT: if the certificate holder is an AD - i'' on this certi
INSURED, R D• the policy {ies) must be endorsed• !f SUBROGATION I5 WAIVED, Subject to
the terms and conditions of the Policy, certain Po
certificate holder in lieu of such endorsement( S - CON i
NAM 1(llStSLL� PAX NO. 38 -
pROW10ER PH
Ryder Rosacker McCue & Huston (MOD by Hull & Compa c -3Q 8_38 2
No y AMoDRSS"
W Koenig St NAIL#
Grand Island NE 68802 RRSRrR> � -N G oVMAG €
INSUR>rftA. g
INSURER B s
INSURED INSURER c;
Ka- Boomers Enterprises, Inc. INSURER 0:
dba Kai- B Fireworks INSURERE;
PO Box 86
Wahoo NE 68066 INSU F.
}2 Bit SIOIV NUMBER:
CERTIFICATE NUMB
COVERAGES Et:1602870655 AB A Fpg TIi PO Y PERIOD
T Is TQ CERTIFY THAT THE POLICIE S OF !N5 Ulu d.CE 119TF0 t3!iLOW HAVE BEEN IsSIJE0 TO 11IE INSUREL? NAM
INDICATED. NOTWITHSTANDIAICz ANY REQUIREMENT, OR CONDMON OF ANY CO OR OTHER E - ENT WITH RESPECT ALL WHICH THI5
CERTIFICATE MAY l3e ISSUED' OR MAY PERT TIES HE I SHOWN EPYF HAVE BEEN REDUCER BY PAIDMSp HEREIN IS 3UBJECTD To Os ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OFSUCH P06� M O jyun D
HO
'LTR POLICY NUMBER
TYPE OFWSURANCH ! R 51935D79 11b12WA 115(2013 EACGCUKRENGE $5,000000
A GrtRtsRA1 taAan nY �`r netsi TO $100 ' $100 000
CQMMERCfAL GENERAL LIABILITY meD CKP (An Ono rson 55,000
CLAIMS -MADE KOCCUR PERSONALSADVINJURY $5 000,000
GENEIMAGGREGATE $5,000,000
PRODUCTS- COMPIOPAGG $5,000000
GEN' LAGGREGATE LIMIT APPLIES PER:
)( POLICY f'M LOG accident
AUTOMOBILELIABIL97Y 501DILYINJURY(PBSpem?P) $
ANY AUTO BOOILY INJURY (Per•accidetIV S
SCHEDULED
ALL OWNED PRQPERTYDAMAGE $
AUTOS r accident
N N..OWNED $
HIRED AUTOS AUTOS
EACH OCCURRENCE $
UMBRELLA LIAO OCCUR AGGREGATE $
EXCESS LIM CI AIMS-MADE $
DED RETENTIONS we STI OTH
WORKERS COMPENSATION RI.. EACH A $
AND EMPLOYERS UA9{LtTY YIN
ANY PROPRIETOR /PArtRTNER'SXECUTIVE E J NIA
E L DISEASE-FJl E 7PLOY $
OFFICERIMEMBER EXCLUDED? j �7
(Mandatory In NH)
EL DISEASE - PQLIGY LIMIT $
If Yes. descrfbe under
DESCRIPTION OFOPERATIONS betrnv
S $01111 ON OF OP Ar'°NS r LacA�rc+NSI vaaRtcL>~snti es !steel below per attached form '
G 5 150s when required by written agreement.
Blanket Additional Insured applies to the the Church
St
Ci ty of Lti n:
B dca P 13th & Butter
CAIUCELLATION
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CAPlGU�im &EFORC
IMg EXpIR IO N 11tE PO R P U NSE WILL 06 DELMMED IN
City of Blair AC I
218 S 16th St AUTItORtrRS PRESittATIUE
Blair NE 68008
cr 198E 20110 AC0PD C5ijP KA Tlvro. Ali rigiii; reserves.
AC(3RD 26 (2010
The AGORA name and logo are registered Faarks of ACARA
NEBRASKA STATE FIRE MARSHAL
246 South 14th Stteet
Lincoln, NE 68508-1804
LICENSE FOR SALE OF FIREWORKS
Permissible fireworks may be sold at retail commencing 12:01 AM June 25 and ending 11 PM July 4 OR 12,01 AM
December 20 and ending 11-59 PM December 31 and must be purchased from a licensed distributor or jobber. A jobber
may not sell retail. Invoice copies for ail 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.
LICENSE GOOD ONLY FOR CALENDAR YEAR IN WHICH 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 (M4 $tjpp.). Such license shall be displayed at lJoensees place of business.
DATE RECEIVED:
March 28, 2014 02:12 PM
TYPE OF LICENSE AND FEE:
Retail Permit (July) - $25.00
LOCATION OF OUTLET FOR RETAIL SALE OF FIREWORKS:
13th and Butler COUNTY,
Blair Washington
Tent in parking lot
STORAGE LOCATION:
DISTRIBUTOR($)IJOBBER(S)'.
Ka-Boomers Enterprises, Inc. (2014 -RP- 6743636 -11)
SALES TAX NUMBER: DATE ISSUED:
15671981 March 28,2014 11:52 A : M
STATE FIRE MARSHAL
LICENSE HOLDER., I "
Ka-Boomers Enterprises, Inc. LICENSE NUMBER:
2014-RP-7424774-92-06
•
•
March 5, 2014
Valerie Bellino
Bellino Fireworks, Inc-
5 01 Olson Drive, Suite 210
Papillion, NE 68046
RE: Firework License in Blair
Dear Valerie,
The Blair Special Olympics has been awarded one (1) license nor Mfiare 4 s
received your Certificate of Insurance which will expire o y
iration date as well as your Nebraska State Fireworks Permit
current certificate after your exp
License by June 16, 2014.
Enclosed Y ou will find a map indicating the location of the sp our tent the n eed t g b ed f _s ized
your sal outlet at Vet's Field. Please remember that y to
accordin 1 to allow for setup of the tent along with s torage of al tr e con attached
I
meet the minimum State Fire Marshal stand ards on setback requirements (Please se
P
— to furnish
map layout options and maximum tent size). You are also r own trash accumulation
providing a trash container no larger than six (6) yards to Y
)usiness is r_ aired
see attached map for trash storage). All trash related to firework
for each of the spaces to be
cleaned up daily. The City will provide one 110 volt, 15 amp o utlet
If Y ou have any questions or need additional information, f free to contact me. We look
forward to working with you for a safe and profitable firewor
Sincerely,
j � -, ,//, }
Brenda Wheeler
City Clerk
Cc: Blair Special Olympics, 1152 South St., Blair, NE 68008
218 South 16th Street • Blair, Nebraska 68008 • 402 -426 -4191 •Fax 402-426-4196 •Email cityofblair @ci,bla(r,ne,us
CITY OF BLAIR APPLICATION
FOR FIREWORK LICENSE
1. Calendar Year for Application 2014
2. Name of Applicant Blair Spe
3. Address of Applicant 1152 South BI 'r r
Contact Person Don Trev�rt___ hen_
Phone # (4021960 -4340
4. Is applicant working through a vendor? Yes N No ❑
5. Name of vendor participating with applicant (i£ applicable) Belli ioTAMD&SJ��
6. Addressofvendor 5Q1
Contact Person Valerie Belling
Phone # (40 _,_ -2 -� 916
'7. Is certificate of insurance held by applicant or vendor? Vendor � Applicant ❑
g. If held by vendor, does insurance name applicant and city as additional insurers?
Yes ® No El
9. License fee - $5,000 (Attached)
10. Certificate of Insurance (Attached)
11. Sales Tax # 3 4j e (Name of Holder) B ellin
n FirawnrkS Inc'
11we, the authorized representative Of the above applicant and/or vendor, do hereby make application for a
fireworks license to be issued by and through y f the Nebraska Nebraska. I/we further and State o£ Nebraska
all regulations and ordinances of the o this
Cit
application and the sale and storage of fireworks in the City of Blair, Nebraska.
FOR CITY USE ONLY'
Date Received Time Received _
Applicant awarded license: Yes ❑ No El
DATE RECEIVED:
May 29, 2014 02:10 PM
COUNTY:
Washington
DATE ISSUED:
May 29, 2014 12:17 PM
STATE FIRE MARSHAL
LICENSE NUMBER:
2014 -RP- 8238280 - 321 -02
LICENSE HOLDER:
Bellino Fireworks, Inc.
I O I DATE (MMIDDIYYYY)
p 05/29/2014
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 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
Birmingham, AL 35202
INSURED
Bellino Fireworks, Inc
501 Olson Drive, Suite 210
Papillion, NE 68046
800- 476 -2211
A :James River
B:
C:
INSURER E:
NAIC #
COVERAGES CERTIFICATE NUMBER:SVH8WH3J REVISION NUMBER:
THIS ISTO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE INSURED NAMED ABOVE FORTHE 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
I LTR
TYPE OF INSURANCE
ADDLSUBR
VD
POLICY NUMBER
MM/D
MM /DD /YYYY
LIMITS
A
GENERAL LIABILITY
000576611
05/04/2014
09/0412015
EACH OCCURRENCE
$ 2,000,000
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE FRI OCCUR
DA GET
PREMISES Ea occurrence)
$ 1,000,000
MED EXP (Any one person)
$ EXCLUDED
PERSONAL &AOV INJURY
$ 2,000,000
GENERAL AGGREGATE
$ 5,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
$ 2,000,000
X POLICY PRO- LOC
$
AUTOMOBILE
LIABILITY
Ee accide D SINGLE LIMIT
$
BODILY INJURY (Per person)
$
ANY AUTO
ALLOWNED SCHEDULED
AUTOS AUTOS
Per accident
BODILY INJURY ( )
$
NON -OWNED
HIRED AUTOS AUTOS
PROPERTY DAMAGE
Per accident
$
A
X
UMBRELLA Line
OCCUR
000623090
05/04/2014
09/04/2015
EACH OCCURRENCE
$ 4,000,000
AGGREGATE
$ 4,000,000
EXCESS LIAB
CLAIMS -MADE
DED I I RETENTION $
$
WORKERS COMPENSATION
WC STATU- OTH-
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE a
OFFICER/MEMBER EXCLUDED?
NIA
TORY L1MIT5 I R
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
(Mandatory In NH)
If yes, describe under
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)
Location: 1301 Butler St., Blair, NE
City of Blair, NE
Blair Special Olympics
Bellino Fireworks, Inc.
Donald J. and Valerie R. Bellino
a+V-rcr rrwMI r- nVI-LOMM GAN"LL.AI IVN
SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Bellino Fireworks, Inc.
501 Olson Drive Suite 210
Papillion, NE 68046
AUTHORIZED REPRESENTATIVE