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

AGENCY CUSTOMER ID: APPL&HO-01 LOC #: ________________ ADDITIONAL REMARKS SCHEDULE <table> <tr> <th>AGENCY</th> <td>TrueNorth</td> <th>NAMED INSURED</th> <td>Appleby & Horn Tile Co.<br>PO Box 1545<br>Cedar Rapids IA 52406</td> </tr> <tr> <th>POLICY NUMBER</th> <td></td> <th>NAIC CODE</th> <td></td> </tr> <tr> <th>CARRIER</th> <td></td> <th>EFFECTIVE DATE:</th> <td></td> </tr> </table> ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Chad French is an excluded officer. #250120 – City of Tiffin Community Recreation Center-BP#2 105 S. Park Rd, Tiffin, IA 52340 Miron Construction Co., Inc., and Sunshine Leasing, LLP, City of Tiffin, Atura Architecture, including their officers, directors and employees are listed as additional insured with regards to the General Liability while under written contract or agreement. Waiver of subrogation applies to the General Liability and Workers Compensation. Umbrella follows form. 30-day notice of cancellation applies. Stored materials in the amount of: $5,665.00