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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, Stale, Zip <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, 3i' 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 07101/2016 until canceled. <br />Company's Limits of Liability Statutory each occurrence. <br />Self -Insurer's Retention $500,000 each occurrence. <br />Dated this 21st day of June 20 16 <br />STATE NATIONAL INSURANCE COMPANY INC <br />Name of Excess Insurance Company <br />Authorized Representative' <br />DEAN M. WILLIAMS, PRESIDENT <br />Print Name of Representative <br />440-605-5100 <br />Phone Number including Area Code <br />Attach evidence of authority �ed'ay <br />e <br />SI -21 (04-05)e�� <br />