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CERTIFICATE OF EXCESS INSURANCE CONTRACT FOR SELF -INSURER <br />STATE NATIONAL INSURANCE COMPANY INC <br />Name of Excess Insurance Cam or <br />C/O US SPECIALTY UNDERWRITERS <br />THIS IS TO CERTIFY 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, 3" 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 -0927470.17 <br />Contract Effective 07/01/2017 <br />Company's Limits of Liability Statutory <br />Sei6lnsurees Retention $600,000 <br />Dated this 201h <br />day of <br />until canceled. <br />each occurrence. <br />Z6 \6A1 <br />!aG°�V-dC�`!� 0\ <br />6 J <br />' Atlech evidence of aulhonty ^ , 19P <br />SI -21 (04-05) �x <br />each occurrence. <br />June 20 17 <br />STATE NATIONAL INSURANCE COMPANY. INC <br />Name of Excess Insurance Company <br />Authodzad Representative' <br />DEAN M. WILLIAMS PRESIDENT <br />Print Name of Ropresentatve <br />440-505.6100 <br />Phone Number Including Area Code <br />