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CERTIFICATE OF EXCESS INSURANCE CONTRACT FOR SELF -INSURER <br />STATE NATIONAL INSURANCE COMPANY, -INC. <br />Name of Excess Insurance Carrier <br />CIO US SPECIALTY UNDERWRITERS <br />6140 PARKLAND BLVD, SUITE 300, MAYFIELD HEIGHTS, OH 44124 <br />Address, City, State, Zip <br />THIS IS TO CERTIF=Y that a Workers' Compensation Excess Insurance Contract has been issued by this <br />Company as follows: <br />The Excess Insurance Contract is now in force and the Company will give the Chair, Workers' Compensation <br />Board, Attention: Office of Self -Insurance, 328 State Street, 3rd Floor, Schenectady, NY 12305 not less than thirty <br />(30) days written notice of cancellation or of any change to be made by the Company in said Contract. Such <br />notice shall be sent by registered or certified mail or delivered by personal service as required in the Contract. <br />Name <br />Self -Insurer Queens Borough Public Library <br />Address 89-11 Merrick Blvd., Jamaica, NY 11432 <br />Contract Number NDE -0864177-16 <br />Contract Effective 07/01/2016 <br />until canceled. <br />Company's Limits of Liability Statutory each occurrence. <br />Self -Insurer's Retention $500,000 <br />Dated this 21st day of <br />e6 `Y2 <br />:,jN�a L <br />CPV <br />" Attach evidence of authortvy� <br />SI -21 (04-05) <br />June <br />each occurrence. <br />20 16 <br />STATE NATIONAL INSURANCE COMPANY, INC. <br />Name of Excess Insurance Company ^T <br />Authorized Representative <br />DEAN M. WILLIAMS, PRESIDENT <br />Print Name of Representative <br />440-605-6100 <br />Phcne Number including Area Code <br />