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Aco CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDD/YYYY) 01/18/2012 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 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Faribo Ins. In PHONE FAX rar Ext): (A/C, Nol: 1404 NW 7Th Street ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC N Faribault MN 55021 INSURER A: Nautilus Insurance Company 17370 INSURED INSURER B Final Stretch Inc. INSURER C : PO Box 121 INSURER D : 12447 150Th St E INSURER E : Nerstrand MN 55053 INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. INSR ADDLSUBhr POUCY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) OMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 100,000 CLAIMS -MADE © OCCUR MED EXP (Any one person) s 5,000 A _ NN201055 01/22/2012 01/22/2013 PERSONAL A. ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIESPER• PRODUCTS S INCLUDED o- n 7 POLICY n .7. LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _ (Es accident) ANY AUTO This Insurance is issued pursuant to the BODILY INJURY (Per person) _ $ ALL OWNED SCHEDULED BODILY INJURY per accident) S AUTOS _ AUTOS Alitmesota Surplus Lines Insurance Act. The _ HIRED AUTOS _ AUUTOS� Insurer is an eligible surplus lines insurer but Pe °accidentDAMAGF. S ) is not otherwise licensed b`, The State of s _ UMBRELLA UAB OCCUR Minnesota. In case of insolycnct. pas ntent EACH OCCURRENCE _ S EXCESS UAB CLAIMS -MADE Of claims is not guaranteed. AGGREGATE S _ DED 1 RETENTIONS i S WORKERS COMPENSATION 1 7 S SIAM- I I OT AND EMPLOYERS' UABIUTY Y 1 N FR ANY PROPRIETOR/PARTNER /EXECUTIVE N / E.L. EACH ACCIDENT S OFFICER/MEMBER EXCLUDED (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes des und DESCRIPTION OF O PERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Name /Date of Event: Diva Dash 11/10/2012 Certificate holder is name as additional insured if required by written contract CERTIFICATE HOLDER CANCELLATION City of Centerville Employees, officers and assigns SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1880 Main Street ACCORDANCE WITH THE POUCY PROVISIONS. Centerville MN 55038 AUTHORIZED REPRESENTATIVE 1 r © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD