Discussion and Consideration of Pay Application #9 – Miron Construction – Tiffin Recreation Center – Motion to Approve — K-3

AGENCY CUSTOMER ID: ILTEINC-01 LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Skogman Insurance Agency Ilten's Inc. 919 14th Ave SW POLICY NUMBER Cedar Rapids IA 52404 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE (including products & completed operations) on the Auto Liability by written contract, Miron Construction Co., Inc., and Sunshine Leasing, LLP, City of Tiffin, Atura Architecture are included as a primary & non-contributory additional insured on the General Liability and the Auto Liability. If required by written contract, a Waiver of Subrogation applies on the General Liability and Auto Liability, in favor of the below listed Certificate Holder. Umbrella follows form in regard to the underlying coverages. A Third Party (30 Day) Notice of Cancellation has been endorsed in favor of the below listed certificate holder, subject to policy conditions. A Non-Waiver of Governmental Immunities has been added in favor of City of Tiffin. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD