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<br />11/22/2006 WED 11:51 FAX 763 694 9955 THE INTERAGENCY <br /> <br />~ 004/004 <br /> <br />P.O. Bo)('5900 <br />Madison. WI 53705 <br /> <br />THIS FORM CHANGES THE POLICY. PLEASE READ TI-1IS FORM. <br /> <br />ADDITIONAL INSURED - <br />STATE OR POLITICAL SUBDIVISIONS - PERMITS <br /> <br />This form changes the policy terms as follows: <br /> <br />COMMERCIAL LIQUOR LIABILITY COVERAGE PART <br /> <br />SCHEDULE <br /> <br />State or Political Subdivision: <br /> <br />City of Cente~ville <br />1880 Main Street <br />Centervil1e, MN 55038 <br /> <br />(If no entry appears above. information required to complete this form will be shown in the Declarations as <br />applicable to this form.) <br /> <br />WHO ISAN INSURED (Section II) is amended to include as an insured any state or political subdivision shown in <br />the Schedule. subject to the following provisions: <br /> <br />1. This insurance applies only with respect to operations performed by you or on your behalf for which the <br />state or pOlitical subdivision has issued a permit. <br /> <br />2. This insurance does not apply to: <br /> <br />a. bodily iniury. procertv damage. Deroohal iniurv. or advertising iniurv arising out of operations <br />performed for the state or municipality; or <br /> <br />b. Bodilv iniurv or I2rooerty damage included within the products-completed operations hazard_ <br /> <br />Words or terms underlined In this form have special meaning and are defined in the policy or in this form. <br /> <br />CLQ 001 (01-98) <br /> <br />35 <br />