Discussion and Consideration of Pay Application #12 – Miron Construction – Tiffin Recreation Center Project – Motion to Approve — K.2

DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 08/25/2025 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 Josh Stafford NAME: Phillips Stafford Insurance Group PHONE FAX (A/C, No, Ext): (A/C, No): 809 8th St SW E-MAIL [email protected] ADDRESS: Suite D INSURER(S) AFFORDING COVERAGE NAIC # Altoona IA 50009 INSURER A : Columbia National Insurance 19640 INSURED INSURER B : Columbia Insurance Company 40371 Phillips' Floors, Inc INSURER C : Philadelphia Contributorship 17914 1605 N 9TH ST INSURER D : INSURER E : Indianola IA 50125 INSURER F : COVERAGES CERTIFICATE NUMBER: CL2582510018 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 INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ MED EXP (Any one person) $ 5,000 A Y Y CMPIA2000025839 07/01/2025 07/01/2026 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- 2,000,000 POLICY JECT LOC PRODUCTS - COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY (Per person) $ B OWNED SCHEDULED Y Y CAPIA2000025839 07/01/2025 07/01/2026 BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 8,000,000 A EXCESS LIAB CLAIMS-MADE Y Y CUPIA2000025839 07/01/2025 07/01/2026 AGGREGATE $ 8,000,000 DED RETENTION $ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? Y N/A Y WCPIA2000025839 07/01/2025 07/01/2026 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 Employment Practices $1,000,000 Employment Practices Liability Liability Insurance C PHSD1873493-001 07/01/2025 07/01/2026 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Project: 250120; City of Tiffin Community Recreation Center; 105 S Park Road, Tiffin, IA 52340 Miron Construction Co., Inc., and Sunshine Leasing, LLP, City of Tiffin, Atura Architecture, including their officers, directors, and employees, and all other parties required by the Prime Contract are named as additional insured on the general liability for ongoing and completed operations, auto and umbrella policies on a primary and non-contributory basis. Waiver of subrogation applies to same parties on the general liability, auto, workers compensation and umbrella policies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Tiffin & Miron Construction Co., Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 335 French CT. AUTHORIZED REPRESENTATIVE Cedar Rapids IA 52404 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD