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<br />~1B/84/H5 12:58:45 <br /> <br />DEFAULTCSID -} <br /> <br />Pa.ge BBl <br /> <br />" <br /> <br />ACORDCERTIFICATE OF LIABILITY INSURANCE I DATE (MI\NDDIYV) <br /> 1M October 4, 2005 <br />PRODUCER (630)324-2500 FAX (630)324-2501 THI F .1= 11:1'"'> "'SA MATTER OF INFORMATIn\J <br />T. J. Adams Group, a Hilb Rogal & Hobbs Company O\IL Y AND<XJNFERS NO RGHTS UPClN THECERTIR::ATE <br />Ha...cER. THISCffiTIFICA TE DOES NOT AMEND EXTEND OR <br />333 E. Butterfield Rd., Suite 500 Al rf.A' <br />Lombard, IL 60148 NSURERSAFFORDNGCOVERAGE <br />INSI.R:D INSURER A: ACE American II'l5l..lra"1Ce <br />8enterville Lions Club INSURERB: <br /> INSURER c: <br />Minnesota INSURER D: <br /> INSURER E: <br />~.~~ <br />IHe ,;:,;:,ut:u IU Mt: <br />ANYREQUIREMENTTERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTWITH RESPECTTOWHICH THIS CERTIFICATE MAY BE ISSUED OR <br />MAY PERTAIN TI-E INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONSANDCONDmoNS OF SUCH <br />POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />~ lYPEOFNSURANCE POLK::YNUMBER ~~~~1~h58tWf= "&W~~ LIIVDTS <br /> GENERAL LIABILITY EACH OCCURRENCE $ 1 000 000 <br /> - $ <br /> X COMMERCIO.l GENERAl LIABILITY RRE DAMAGE (l'nyooel"e) 1 000 000 <br /> I a..AIMS MADE 0 0CClR MED EXP ~one persal) $ 1 (XX) <br />A 1-IXlG21731933 00I0112CXJ5 00101/2006 PERSONAL &ADV INJURY $ 1 0CXl 0CXl <br /> - <br /> GENERAL AGGREGATE $ 2000000 <br /> GEm. AGGREGATE LIMIT APPLIES PER: PRODUCTS - COI\/PIOP AGG $ 2,000000 <br /> I POLICY nPROJECTn LOC <br /> AUTOMOBILE LIABILITY COMBNEDSI\IGLELIIIIIT $ Included in Above <br /> - (per accidenl) <br /> ANY AUTO <br /> - <br /> ALL OWNED AUTOS BODILY INJURY <br /> - HlXX321731936 CBOt/2aJ5 C901!2f:D3 (per person) $ <br /> SCHEDUUED AUTOS <br />A X O\I\A\IEDAUTOS NOT c::cJv'ffiED <br /> HRED AUTOS BODILY INJURY <br /> X (per acddenO $ <br /> NON-OWI\ED AUTOS <br /> - <br /> - PROPERTY DAMAGE $ <br /> (per acddenO <br /> GA ~GE LIABILITY AUTO ONLY - EA ACODENT $ <br /> ANY AUTO NOTOOVERED OTI-1ER 1HAN EAACC $ <br /> - AUTO ONLY: <br /> AGG $ <br /> EXCESS LIABILITY EACH OCCURRENCE $ <br /> - D aLAlMS MADE <br /> 0CClR AGGREGATE $ <br /> - NOT COVERED $ <br /> - <br /> DEDUCllBLE $ <br /> - <br /> RETENfION$ $ <br /> WORKERS COMPENSA TION AND I ~~~~t~~s I I OTHER <br /> EMPLOYERS' LIABILITY NOTOOVERED <br /> E LEACH AGaDENT $ <br /> E L DISEASE- EA EMPLOYEE $ <br /> E L DISEASE - POLICY L1IV1T $ <br /> <br />DESCRIPTION OF OPERA TIONS/LOCA TIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS <br /> <br />Provisions of the policy apply to the Centerville Lions Club for their participation in the 13th Annual Haunted House on October <br />1-22 & 28-29, 2005 or any other dates during the policy period. <br /> <br /> <br />he City of Centerville is an additional insured, but ONLY with respect to liability arising out of the Use of Premises by the <br />enterville Lions Club and not out of the sole negligence of the said additional insured. <br /> <br />PROVISIONS OF THE POLICY DO NOT APPLY TO THE SALE OR SERVING OF ALCOHOLIC BEVERAGES. <br /> <br /> <br />ADDITIONAL INSURED; INSURER LETTER <br /> <br />ity of Centerville <br />1880 Main Street <br />enterville, MN 55038 <br /> <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE <br />EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL <br />~ DAYS WRlT1lEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, <br />BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY <br />OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. <br />A S A <br />JohnE.Adams,C.P.C.U dolwv 6. ~ <br /> <br />~=/$~ <br />