2015-12-09 CC Packet - Laserfiche WebLink

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INSURED MEMBER GENERAL LIABILITY DECLARATIONS CERTIFICATE Insurance Company: GREAT AMERICAN E&S INSURANCE COMPANY Address: RICHMOND,VA Policy Number: PL 3717684 Certificate Number: 0210 Policyholder: Sports And Special Event Risk Purchasing Group, Inc.A Risk Retention Purchasing Group Filed Under The Risk Retention Purchasing Group Act Of 1986. Address: P.O. Box 1250,Midlothian,VA 23113-1250 INSURED MEMBER AND ADDRESS Lions Club of NIN Coverage Effective Date: 06/30/15 c/o The Christensen Group Coverage Expiration Date: 06/30/16 11100 Bren Road West Both At 12:01 AM At The Address Of Minnetonka,MN 55343 The Insured Member. Insured Operations: Charitable Events Clubs(14) Location:Various $2,000,000 General Aggregate Per Participating Member $2,000,000 Products-Completed Operations Aggregate Limit $1,000,000 Each Occurrence Limit $1,000,000 Personal And Advertising Injury Liability Limit $ 100,000 Damage to Rented Premises $ 5,000 Medical Expense Limit Any One Person $ 0 Deductible Each Claim $1,000,000 Liquor Legal- $1,000,000 OCC/$2.000,000 AGG The Coverage Afforded Is Subject To Policy Limits,Terms And Conditions. The Above Is A Recitation, And Does Not Provide Separate, Increased Or Additional Limits. This Certificate Evidences That Coverage Exists For The Insured Operations. Premium,Taxes And Service Provider Fees Premium: $10,150.00 Program Administrative Fee: $ 350.00 State Tax: $ 304.50 Stamping Fee: $ 60.90 Broker Fee: $ 11015.00 Total Member Charge: $11,880.40 +$350 Policy Fee This Endorsement/Certificate Is Issued At The Request Of: USG Insurance Service. Inc. Dated At Richmond,Virginia 6/29/2015 lohn W Frazier John W. Frazier, Authorized Representative SSERPG-01- & SPECIAL EVENT RISK PURCHASING GROUP, INC. `e 1 of 2 100