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

CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFFERS 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 TrueNorth PO Box 1863 500 First Street SE Cedar Rapids IA 52406-1863 CONTACT NAME: TrueNorth Risk Management PHONE: 319-366-2723 FAX (Loc. No): 877-810-6374 E-MAIL: [email protected] ADDRESS: [email protected] INSURER(S) AFFORDING COVERAGE INSURER A: United Fire & Casualty Company 13021 INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: INSURED Appleby & Horn Tile Co. PO Box 1545 Cedar Rapids IA 52406 APPL&HD-01 COVERAGES CERTIFICATE NUMBER: 939183052 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. <table> <tr> <th>INSR/CTR</th> <th>TYPE OF INSURANCE</th> <th>ADD/SUBR INSD WO#</th> <th>POLICY NUMBER</th> <th>POLICY EFF (MM/DD/YYYY)</th> <th>POLICY EXP (MM/DD/YYYY)</th> <th>LIMITS</th> </tr> <tr> <td>A</td> <td>COMMERCIAL GENERAL LIABILITY<br>CLAIMS-MADE X OCCUR</td> <td></td> <td>60468948</td> <td>11/1/2025</td> <td>11/1/2026</td> <td>EACH OCCURRENCE $1,000,000<br>PREMISES (Ex occurrence) $100,000<br>MED EXP (Any one person) $5,000<br>PERSONAL & ADV INJURY $1,000,000<br>GENERAL AGGREGATE $2,000,000<br>PRODUCTS - COMP/PROP AGG $2,000,000<br>S</td> </tr> <tr> <td>A</td> <td>GEN'L AGGREGATE LIMIT APPLIES PER:<br>POLICY X LOC</td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td>A</td> <td>AUTOMOBILE LIABILITY<br>X ANY AUTO<br>X OWNED AUTOS ONLY<br>Hired Autos Only X SCHEDULED AUTOS<br>X NON-OWNED AUTOS ONLY</td> <td></td> <td>60468948</td> <td>11/1/2025</td> <td>11/1/2026</td> <td>COMBINED SINGLE LIMIT (Ex accident) $500,000<br>BODILY INJURY (Per person) $<br>BODILY INJURY (Per accident) $<br>PROPERTY DAMAGE (Per accident) $<br>S</td> </tr> <tr> <td>A</td> <td>UMBRELLA LIAB<br>X OCCUR<br>EXCESS LIAB<br>DED X RETENTION $0</td> <td></td> <td>60468948</td> <td>11/1/2025</td> <td>11/1/2026</td> <td>EACH OCCURRENCE $6,000,000<br>AGGREGATE $6,000,000<br>S</td> </tr> <tr> <td>A</td> <td>WORKERS COMPENSATION AND EMPLOYERS' LIABILITY<br>ANY PROPRIETOR/PARTNER/EXECUTIVE<br>OF POLICYHOLDER EXCLUDED?<br>(Mandatory in NH)<br>If yes, describe under DESCRIPTION OF OPERATIONS below</td> <td>Y/N</td> <td>30305010</td> <td>11/1/2025</td> <td>11/1/2026</td> <td>X PER STATUTE<br>E.L. EACH ACCIDENT $500,000<br>E.L. DISEASE - EA EMPLOYEE $500,000<br>E.L. DISEASE - POLICY LIMIT $500,000</td> </tr> <tr> <td>A</td> <td>Professional Liability</td> <td></td> <td>60468948</td> <td>11/1/2025</td> <td>11/1/2026</td> <td>Each Occ Aggregate<br>1,000,000<br>2,000,000</td> </tr> </table> DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required). If Yes is indicated above for addl insd forms Gen Liab #CG7201 (premises), & (completed operations), Auto Liab #CA7109 applies. If Yes is indicated above for waiver of subrogation forms Gen Liab #CG7201, Auto Liab #CA7109 and WC #WC000313 04/84 applies. Coverage is extended for work performed and required under written contract with the above-named insured. General Liability and Auto Liability Primary and Non-Contributory applies when under written contract. Umbrella follows form and extends over the General Liability, Automobile Liability and Workers Compensation/Employers Liability policies. See Attached... CERTIFICATE HOLDER Miron Construction Co., Inc 335 French Ct SW Cedar Rapids IA 52404 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. AUTHORIZED REPRESENTATIVE [signature] © 1988-2015 ACORD CORPORATION. All rights reserved.