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AGENCY CUSTOMER ID: 31RH20229 <br /> LOOS: <br /> A` oa° ADDITIONAL REMARKS SCHEDULE Page _2_of <br /> AGENCY NAMED INSURED <br /> Centerville Lions Club <br /> Willis of Illinois, Inc. 7155 Brian Drive <br /> POIKYNUMDER Centerville, MN 55038 <br /> See First Page <br /> CARRIER NAIC CODE <br /> ACE American Insurance Company 22667 -002 EFFECTIYEDATE: See First Page <br /> ADDITIONAL REMARKS <br /> THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br /> FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE <br /> City of Centerville is included as an Additional Insured, but only with respect to General <br /> Liability arising out of the use of premises by the Insured shown above and not out of the sole <br /> negligence of said Additional Insured. <br /> ACORD 101(2008101) Co11:3482576 Tp1:1312953 Cert:16521674 ®2008ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br /> 22 <br />