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,�►co n` CERTIFICATE OF LIABILITY INSURANCE DATE <br /> FRooucot THIS CERTIFICATION IS ISSUED AS A MATTER OF FORMATION <br /> YWIls d Mirtcis. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA <br /> 233 S. Wacker Od". Suite 2000 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND O <br /> pNcW. IL 60606 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br /> Phase (800) 316.6705 Fax: (312) 234-0638 INSURERS AFFORDING COVERAGE NAIL I <br /> "NAM NSuRER A ACE Ait)erit m Inmarce Company 2W <br /> Centerville Lions Club - 5M7 INSURER 8 <br /> Centerville, MN USA <br /> INSURER C. <br /> INSURER D. <br /> INSURER E' <br /> THE POLICIES OF INSURANCE EISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N07WVFTHSTANOW46 <br /> COVERAGES <br /> ANY REOU1REMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WnH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR <br /> MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH <br /> POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> LTR TYPEOFM/WRANCE POUCYNUMBER DAN 6 T Lam <br /> 084MAL LIABKM CS=13066 0910112009 09101/2410 EACH OOCURRMOE s 1000 004 <br /> A X COMMERCIAL GENERAL LI48LITY M15 a oour i 1.000.000 <br /> CLAIMS MADE MR OCCUR MEDEXP(Anyoneporm) i 1.00D <br /> PERSONAL S ADV IN"Y i 1.000.004 <br /> GENERAL AGGREGATE i 2.OW.ODD <br /> GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS- COIdP/OP ASG j 2.OW. <br /> POLICY .Ec X LOC CAPPING LMTS END i 10.000. <br /> A AUTOMOBLE LIABLITY CSZD313066 09101/2009 09101/'1010 COMBINED SINGLE LIMIT i INCLUDED <br /> ANY AUTO (ag ecdarn) <br /> ALL OWNED AUTOS <br /> sau MXEDAUTOS (�peYsINar'1) tiRY t IN ABOVE <br /> X HIREDAUTOS ODDLY INJURY <br /> X NON- OIMIEDAUTOS (Pyre0pOM1) : <br /> PROPERTYDAMAGE i <br /> (Persccidtwit) <br /> 406PAGELIABLITY AUTO ONLY .EAACC06W i <br /> ANY AUTO <br /> OTHER THAN EA ACC i <br /> AUTO ONLY: AGG i <br /> EXCESS /IIM181RBLA a IABLITY EACH OCCURRENCE _ <br /> OCCUR CLAIMSMADE AGGREGATE ; <br /> i <br /> DEDUCTIBLE i <br /> RETENTgN i i <br /> WORKERS COMPEI"YM AND <br /> BM►LOYNtr UASLflY TORY T S <br /> ANY PROPRIETORIPARTNISVEXECUT1VEa EL. E ACH ACCIDENT i <br /> OFFICERAIE14W EX(LWED7 <br /> Uyes.dMa AOInitIrldN EL DISEASE -EA EMPLOYE i <br /> OTHER: EL DISEASE - POLICY LIMIT I i <br /> DEiCRWFM OF OPERATIONS I LOCATIONS t VOOCLES /EXCLUSIONS ADDED BY @DORNMENr I SPECIAL MRO VMI" <br /> Provisions of the policy apply to the named insureds participation in the following activity during the policy period shown above: Centerville Lions Ice Fishing Contest - 2116/2012 <br /> Anoka County Sheriff, 1503 Bunker Lake Blvd., Andover, MN 55304 is included as an Additional Insured(s), but only with respect to General Liability arising out of the issuance of permit(s) to the <br /> Insured shown above and not out of the sole negligence of said additional insured. <br /> PROVISIONS OF THE POLICY DO NOT APPLY TO THE SALE OR SERVING OF ALCOHOLIC BEVERAGES <br /> C'1y of Centerville SNOUD ANY OF THE ABOVE DEZ MMW POLIM BE CANCELM BEFORE TIE EXPIRATION <br /> 1880 Main Street <br /> Centerville, MN USA 55038 DATE INEFEW. TIEISSUNGNSIRHtWLLENDEAVORTONAL N DAYS Vli TM <br /> NOTICE TO TIE CERTIFICATE HOUM NAMEDTO THE LEFT. BUT FALtRE TO DO EO SHALL <br /> IMPOSE NO ONLIGATION OR LMBLW OF ANY WND UPON THE DOAML ITS AGWM OR <br /> RM4tBNWATP#VL <br /> ,john ff. ems <br /> ACORD 25 (2408101) 0 1868-2009 ACORD CORPORATION. All ripllts rearvsd <br /> 35 <br />