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HomeMy Public PortalAbout2020.04.08 Knife River McCall Airport - Certificate of Insurance ATE AccPREP CERTIFICATE OF LIABILITY INSURANCE D04/29/2020D/YYYY) 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 have ADDITIONAL INSURED provisions or 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 Marsh USA Inc. NAMEPHONE: FAX 333 South 7th Street,Suite 1400 CA/C.No.Eati: _ (A/C,Noj: Minneapolis,MN 55402-2400 E-MAIL Attn:MDU.CertRequest@marsh.com ADDRESS: INSURERS)AFFORDING COVERAGE NAIC# CN102299309-ALLCP-POLLU-20- INSURER A:Ironshore Specialty Insurance Company 25445 INSURED INSURER B: Knife River Corporation-Mountain West • 5450 W.Gowen Road INSURER C: Boise,ID 83709 INSURER D: INSURER E: t INSURER F: COVERAGES CERTIFICATE NUMBER: CHI-009510604-01 REVISION NUMBER: 3 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSO WVD POLICY NUMBER jMMIDD/YYYYI (MM/DDIYYYVI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ iEa accident) ANY AUTO BODILY INJURY(Per person) $ pOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ •AUTOS ONLY _ AUTOS ONLY _{Per accident)_ I UMBRELLA LIAB _OCCUR EACH OCCURRENCE $ H. EXCESS LIAB CLAIMS-MADE AGGREGATE •$ . DED I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y N ANYPROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED7 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Contractors Pollution Liab. 003461102 01/01/2020 01/01/2021 EACH OCCURRENCE 5,000,000 AGGREGATE 5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Relocate Parallel Taxiway A,Contract No.FAA/AIP No.3-16-0023-027-2020. City of McCall is/are included as additional insured where required by written contract. CERTIFICATE HOLDER CANCELLATION City of McCall SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 216 E.Park St. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN McCall,ID 83638 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee J4-0.4/lP0*+ . fitly:`-f- ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AcoRD® EVIDENCE OF PROPERTY INSURANCE 04/29/2020 DATE M/DDIYYYY) THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW.THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE ADDITIONAL INTEREST. AGENCYPHONE COMPANY ,4p,1C.No.EMI: Marsh USA Inc. Zurich American Insurance Co 333 South 7th Street,Suite 1400 Minneapolis,MN 55402-2400 CN102299309--BR105-20-21 FAX E-MAIL LAIC.Not: ADDRESS: _ CODE: SUB CODE: AGENCY CUSTOMER ID*: INSURED LOAN NUMBER POLICY NUMBER Knife River Corporation-Mountain West CPP3704500-18 5450 W.Gowen Road - Boise,ID 83709 EFFECTIVE DATE EXPIRATION DATE 01/01/2020 01/01/2021 — CONTINUED UNTIL TERMINATED IF CHECKED THIS REPLACES PRIOR EVIDENCE DATED: PROPERTY INFORMATION LOCATION/DESCRIPTION Re:Relocate Parallel Taxiway A,Contract No.FAA/AIP No.3-16-0023-027-2020,Contract Amount 6,633,584.00. 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 EVIDENCE OF PROPERTY INSURANCE 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. COVERAGE INFORMATION PERILS INSURED BASIC [BROAD SPECIAL COVERAGE I PERILS/FORMS AMOUNT OF INSURANCE DEDUCTIBLE "All Risk'Blanket Real and Personal Property including 25,000,000 25,000 Boiler Machinery,earthquake,flood and wind perils. Leased/Rented Contractor's Equipment($2,500,000 per item,$5,000,000 per occurrence) 5,000,000 25,000 Builder's Risk/Installation(See Attached) 25,000,000 25,000 REMARKS(Including Special Conditions) City of McCall is/are included as additional insured where required by written contract. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ADDITIONAL INTEREST CHI-009510606-01 NAME AND ADDRESS X ADDITIONAL INSURED LENDER'S LOSS PAYABLE LOSS PAYEE MORTGAGEE City of McCall LOAN# 216 E.Park St. McCall,ID 83638 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjeeo�, ACORD 27(2016/03) ©1993-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN102299309 LOC#: Minneapolis ACORD ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA Inc. Knife River Corporation-Mountain West 5450 W.Gowen Road POLICY NUMBER Boise,ID 83709 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 27 FORM TITLE: Evidence of Property Insurance BUILDERS RISK COVERAGE DURING COURSE OF CONSTRUCTION SUBJECT TO POLICY TERMS AND CONDITIONS. Any one Building,Structure or Project--$25,000,000 Limit(Deductible$25,000) Transmission and Distribution Lines Work—$25,000,000(Deductible$25,000) Paving,Decking of Bridges--$25,000,000 Limit(Deductible$25,000) SewerNYater or Plumbing—$25,000,000 Limit(Deductible$25,000) Flood-$25,000,000 Limit per Occurrence and Annual Aggregate(Subject to a minimum$25,000 deductible) Earth Movement-$25,000,000 Limit per Occurrence and Annual Aggregate(Subject to a minimum$25,000 deductible) Earth movement in Zones 1 and 2 are subject to a per Occurrence and Annual Aggregate limit of-$15,000,000(Subject to a minimum$25,000 deductible) Other deductibles may apply as per policy terms and conditions. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACC*1 0® CERTIFICATE OF LIABILITY INSURANCE DATE (Moz0D ) 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 have ADDITIONAL INSURED provisions or 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 Marsh USA Inc. PHO PHONE : I _ 333 South 7th Street,Suite 1400 ((A.LC,aO.Ext): _ - IA/C.Not: Minneapolis,MN 55402-2400 E-MAIL Attn:MDU.CertRequest@marsh.com ADDRESS: INSURERS)AFFORDING COVERAGE NAIC# CN102299309-MTWES-GAWX-20- INSURER A:Liberty Mutual Fire Ins Co 23035 INSURED INSURER B:NIA N/A Knife River Corporation-Mountain West 5450 W.Gowen Road INSURER C:Liberty Insurance Corporation 42404 Boise,ID 83709 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CHI-009510592-00 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 POLICY EFF POLICY EXP I LTR TYPE OF INSURANCE jINSD�ffivnI POLICY NUMBER iMM/DDIYYYYI IMM/DD/YYYYLI LIMITS A X COMMERCIAL GENERAL LIABILITY TB2-641-005097-040 01/01/2020 01/01/2021 EACH OCCURRENCE $ 2,000,000 TO RENTED CLAIMS-MADE X OCCUR -DAMAGE PREMISES Ea occurrence) ,$ 1,000,000 MED EXP(Any one person) $ 10,000 PERSONAL BADVINJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY X 11, LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ A AUTOMOBILE LIABILITY Al2-641-005097-050 01/01/2020 01/01/2021 COMBINED SINGLE LIMIT $ 2,000,000 (Ea accidenty X ANY AUTO BODILY INJURY(Per person) $ OWNED ' SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS x HIRED x NON-OWNED PROPERTY DAMAGE $ , AUTOS ONLY . AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WA7-64D-005097-010(AOS) 01/01/2020 01/01/2021 X PER STATUTE _ERH C AND EMPLOYERS'LIABILITY Y/N WA7-64D-005097-020(Regulated) 01/01/2020 01/01/2021 ANYPROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? "'INCLUDES"STOP GAP""' 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ • DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Relocate Parallel Taxiway A,Contract No.FAAIAIP No.3-16-0023-027-2020. City of McCall is/are included as additional insured under general liability per the attached CG 2010 and CG 2037 endorsements and does not include professional liability coverage.Blanket Additional Insured for Automobile Liability is included per attached designated Insured Endorsement CA 20 48. CERTIFICATE HOLDER CANCELLATION City of McCall SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 216 E.Park St. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN McCall,ID 83638 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee a�naoi.� ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER:AI2-641-005097-050 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement identifies person(s)or organization(s)who are"insureds"for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. SCHEDULE Name Of Person(s)Or Organization(s): Any person or organization whom you have agreed in writing to add as an additional insured, but only to coverage and minimum limits of insurance required by the written agreement, and in no event to exceed either the scope of coverage or the limits of Insurance provided in this policy. This policy will be primary and non-contributory to any like insurance available to the person or organization noted above. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown In the Schedule is an 'Insured"for Covered Autos LiabilityCoverage,but only to the extent that person or organization qualifies as an "insured"under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2.of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 Policy Number: AI2-641-005097-050 Issued By: Liberty Mutual Fire 'Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule Name of Other Person(s)C Email Address or mailing Number Organization(s): address: Days Notice: • Per schedule of certificate holders Per schedule of certificate holders 90 on file with the Company on file with the Company • A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 ©2011, Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office,.Inc. with its permission. POLICY N UMBER:TB2-641-005097-040 COMMERCIAL GENERAL LIABILITY CG 20 10.0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to 1. All work, including materials, parts or include as an additional insured the person(s) or equipment furnished in connection with such organization(s) shown in the Schedule, but only with work, on the project (other than service, respect to liability for "bodily injury', "property maintenance or repairs) to be performed by or damage or "personal and advertising injury' on behalf of the additional insured(s) d the caused, in whole or in part, by location of the covered operations has been 1. Your acts or omissions; or completed; or 2. The acts or omissions of those acting on your 2. That portion of "your work" out of which the behalf; injury or damage arises has been put to its intended use by any person or organization in the performance of your ongoing operationsforadditionalinsured(s) the other than another contractor or subcontractor tdesignated anave. engaged in performing operations for a principal as a pat of the same project. However: C. With respect to the insurance afforded to these 1. The insurance afforded to such additional additional insureds, the following is added to insured only applies to the extent permitted by. Section III-Limits Of Insurance: law; and If coverage 'provided to the additional insured is 2. If coverage provided to the additional insured is required by a contract or agreement, the most we required by a contract or agreement, the will pay on behalf of the additional insured is the insurance afforded to such additional insured will amount of insurance: not be broader than that which you are required 1. Required by the contract or agreement; or by the contract or agreement to provide for such additional insured. 2. Available under the. applicable Limits of B. With respect to the insurance afforded to these Insurance shown in the Declarations; additional insureds, the following additional whichever is less. exclusions apply: This endorsement shall not increase the This insurance does not apply to "bodily injury' or applicable Limits of Insurance shown in the "property damage" occurring after: Declarations. SCHEDULE CG 2010 0413 ©Insurance Services Office,Inc., 2012 Page 1 of 2 SCHEDULE(continued) Name Of Additional Insured Person(s) Location(s)Of Covered Operations Or Organization(s): Any person or organization with whom you have agreed All locaions as required by a written contract or in writing in a contract or agreement, prior to an agreement entered into prior town "occurrence" or "occurrence"or"offense", that such person or offense. organization be added as an additional insured on your policy;,and 2.Any other person or organization you are required to add as an additional insured under the contract or agreement described in item(1)above. Information required to complete this Schedule,if not shown above, will be shown in the Declarations. CG 2010 04 13 ©Insurance Services Office,Inc., 2012 Page 2 of 2 POLICY NUMBER:TB2-641-005097-040 COMMERCIAL GENERAL LIABILITY CG20370413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance prodded under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for "bodily injury' or If coverage provided to the additional insured is "property damage caused, in whole or in part, by required by a contract or agreement, the most we "your work" at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and included in the"products-completed operations hazard". 1. Required by the contract or agreement;or However: 2. Available under the applicable Limits 'of 1. The insurance afforded to such additional Insurance shown in the Declarations; insured only applies to the extent permitted by whichever is less. law; and This endorsement shall not increase the applicable 2. If coverage provided to the additional insured is Limits of Insurance shown in the Declarations. required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations Any person or organization for whom you have agreed All locations as required by a written contract or in writing in a contract or agreement, prior to an agreement entered into prior to an "occurrence or "occurrence"or"offense", that such person or offense. organization be added as an additional insured on your pdicy, and 2.Any other person or organization you are required to add as en additional insured under the contract or agreement described in item (1)above. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 2037 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number TB2-641-005097-040 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY—UMBRELLA COVERAGE FORM Schedule Name of Other Person(s)I Email Address or mailing address: Number Days Notice: Organization(s); Per Schedule of certificate 90 holders on file with the Company A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above. at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 ©2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. • NOTICE OF CANCELLATION TO THIRD PARTIES: A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below.We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. 6. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. Schedule thole of Other Person(s)! Email Address or mailing:address: Number Days Notice: Organlaation{s): Schedule on file with the Schedule on file with the 90 company company All other terms and conditions of this policy remain unchanged. Issued by Liberty Insurance Corporation 21814 For attachment to Policy No.WA7-64D-005097-010 Effective Date Ol/Ol/2020 Premium$ Issued to Centennial Energy Holdings,Inc. WC 99 20 75 ®2D16 Liberty Mutual Insurance Page 1 of 1 Ed. 12/01/2016 NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. s. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. Schedule Name of Other Person(s)! Email Address or mailing address: Number Days Notice: 0r+ganization{s): Schedule on file with the Schedule on file with the 90 company company Ail other terms and conditions of this policy remain unchanged. Issued by Liberty Insurance Corporation 21814 For attachment to Policy No.WA7-64D-085097-020 Effective Data 01/01/20 Premium$ Issued to MDU Resources Group,Inc. WC 99 20 75 f 2016 Liberty Mutual Insurance Page 1 of 1 Ed.12/0112016