8-Exhibit C.2 COLI SA Conc RFP Sample Certificate.pdf

SAM

PLE

INSR ADDL SUBR

LTR INSR WVD

DATE (MM/DD/YYYY)

PRODUCER CONTACT

NAME:

FAXPHONE

(A/C, No):(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER

POLICY EFF POLICY EXP

TYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

COMMERCIAL GENERAL LIABILITY

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

AUTHORIZED REPRESENTATIVE

INSURER(S) AFFORDING COVERAGE NAIC #

Y / N

N / A (Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

EACH OCCURRENCE $

DAMAGE TO RENTED

$PREMISES (Ea occurrence)CLAIMS-MADE OCCUR

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:

PRODUCTS - COMP/OP AGG $

PRO-

OTHER:

LOCJECT

COMBINED SINGLE LIMIT

$(Ea accident)

BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

AUTOS ONLY

HIRED PROPERTY DAMAGE $

AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE $

CLAIMS-MADE AGGREGATE $

DED RETENTION $ $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below

POLICY

NON-OWNED

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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.

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 any rights to the certificate holder in lieu of such endorsement(s).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)

ACORDTM CERTIFICATE OF LIABILITY INSURANCE

A X X

X X

#S36351398/M36350284

KANSATURClient#: 1253375

VAPZP

#S36351398/M36350284

DATE

Agency Contact Name Agency Contact # Agency Fax #

Agency Contact Email Address

Agency Name Agency Address Agency City, ST ZIP Agency Phone Number

Insured Name Insured Address Insured City, ST ZIP

Carrier Name

Carrier Name

Carrier Name

Carrier Name

Carrier Name

Carrier Name

NAIC #

NAIC #

NAIC #

NAIC #

NAIC #

NAIC #

X Deductible (If Any)

B X

X If Any

Policy Number Eff Date Exp Date 1,000,000

X X Policy Number Eff Date Exp Date 5,000,000 5,000,000

Policy Number Eff Date Exp Date 1,000,000 500,000 5,000 1,000,000 2,000,000 2,000,000

Kansas Turnpike Authority Attn: Credit Manager 9401 E Kellogg Wichita, KS 67207

Mandy.Bookout Typewritten text X X

Mandy.Bookout Typewritten text X X

Mandy.Bookout Typewritten text X X

Mandy.Bookout Typewritten text N

Mandy.Bookout Typewritten text X Policy Number Eff Date Exp Date

Mandy.Bookout Typewritten text X

Mandy.Bookout Typewritten text 100,000

Mandy.Bookout Typewritten text 100,000

Mandy.Bookout Typewritten text 500,000

Mandy.Bookout Typewritten text C

Mandy.Bookout Typewritten text D

Mandy.Bookout Typewritten text Certificate Holder is included as Additional Insured when required by written contract but only with respects to the General Liability, Auto Liability, and Umbrella Liability policies, subject to the provisions and limitations of the policy.

Waiver of Subrogation in favor of the Certificate Holder applies to all referenced policies when required by written contract, subject to the provisions and limitations of the policy.

All policies shall be endorsed to require thirty (30) days notice of cancellation in writing via postal mail and email (rpettersen@ksturnpike.com) prior to the cancellation of any required policy.

Mandy.Bookout Typewritten text Required Signature

Job 1: BNSF Railway Company - JLL