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® DATE (MMIDDIYYYY) <br />�coRo CERTIFICATE OF LIABILITY INSURANCE <br />21312023 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsements . <br />PRODUCER <br />Preferred Insurance Services, Inc. <br />1306 West County Rd F <br />Arden Hills MN 55112 <br />INSURED <br />Midwest Multisport Races LLC <br />2370 County Rd J <br />White Bear Lake MN 55110 <br />cn o1Ab19L Kain Gombold <br />PHONE OL <br />6512877409 AIC.No]:651-255-3502 <br />E-MAIL <br />ADDRESS: kaitlynQreferredmn.com _ <br />INSURERISI AFFORDING COVERAGE NAIL* <br />License#: 20018923 INSURERA: West Bend Mutual <br />MIDWMUL-01 INSURER B <br />INSURER C <br />INSURER D <br />INSURER E <br />COVERAGES CERTIFICATE NUMBER:962709726 REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR ADDCSLFBR POLICY EFF POLICY EXP LIMITS <br />LJR TYPE OF INSURANCE y n POLICYNUMBER DJ3fYY'YY? .MM! Y <br />A X COMMERCIAL GENERAL LIABILITY Y A559999 1129/2023 V2912024 EACH OCCURRENCE I $1,ODOODD <br />F71DAMAGE TO RENTED 30D,000 <br />CLAIMS -MADE OCCUR PREMISES JEa occurrencel., $ <br />MED EXP Anyoneperson) [$EXCLUDED <br />PERSONAL & ADV INJURY 1 $ 1,000,090 <br />GENT AGGREGATE LIMIT APPLIES PER: <br />PRO- <br />X POLICY ❑ JECT ❑ LOC PRC <br />A AUTOMOBILE LIABILITY I A559999 1/2912023 1/29/2024 <br />ANY AUTO <br />I OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />X HIRED Ex NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />A X UMBRELLALIAS X OCCUR <br />EXCESS LIAB CLAIMS-MAUE <br />DED X YRETENTION <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANYPROPRIETORIPARTNERIEXECUT)VE ❑ <br />OFFICERIMEMBER EXCLUDED? N 1 A <br />(Mandatory In NH) <br />If yes, describe under <br />$1.000,000 <br />BODILY INJURY (Per person) $ <br />BODILY INJURY (Per accident) $ <br />PROPERTYDAMAGE $ <br />.Per accident, _ <br />A559999 1/2912023 112912024 , EACH OCCURRENCE __ S 1,000 <br />AGGREGATE $ 1.000 <br />E.L. EACH ACCIDENT $ <br />E.L. DISEASE - EA EMPLOYEE $ <br />E.L. DISEASE -POLICY LIMIT $ <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space is required) <br />Certificate holder is additional insured on General Liability coverage where required by written contract. <br />CERTIFICATE HOLDER <br />City of Centerville <br />1880 Main Street <br />Centerville MN 55038 <br />USA <br />CANCELLATION <br />I SHOULD ANY OF THE: ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE. WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />Q 1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />