Laserfiche WebLink
<br />U~I 11 ~~~4 1~:41 r~ R~lcSYN ENGINEERING 512 392 5740 TO 95514298529 <br /> <br />P.02/02 <br /> <br />ACORD CERTIFICATE OF LIAS I L1TY INSURANCE CATE (MMlDDlVY) <br /> ... October 7,2004 <br />PRODUCER (630)324-2500 FAX (630)324-2501 Tlofl", <br /> Adams Group, llC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br /> E. Butterfield Rd., Suite 500 ~IOT~.,E~;..~IS CERTIFlC~TE DOES, ~8-r;.~~~~ ,;.~g:~~,9..~^, <br />Lombard,lL 60148 INSURERS AFFOROING COVERAGE <br /> INSUR!:R A: ACE American Insurance Comoanv <br /> INSURER B: <br />Centerville Lions Club INSVRER c.. <br />Minnesota INSURE.R. D: <br /> INSUReR ~: <br />ICOVtiRAGES <br />~TH.FOllCIES OF INSURANCE LISTED BELOW I1AVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THe POliCY PERIOD INDICATED. NOTWITHSTANDING <br />A~ REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFIOA TE MAYBE iSSUED OR <br />MAY PI!RTAlN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN is SUeJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH <br />POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, <br />LTR TYPE OF' INSURANCE pOLICY NUMBER POLICV EFFECTIVE POLlCY EXPIRA I N LIMITS <br /> ~NERAL UAIJIUTY EACH OCCUl'iR.ENCE. S 1 000 000 <br />-- ~.ko""."~!Y ..".-_.-- -. -"..-.-- .-. --. F'R~ O~~G.E ~An'J Q~e_~r~ . , 1 "."00",,1 <br /> 1 CLAI". MAOE [[] OCCUR MED EXF' 'Any gn, p.rsOfl) I i OOl <br />A HDOG21731936 09/01/2004 09/01/2005 peRSONAL & ADV INJURY S 1 000 000 <br /> I- GENERAL ABaREOAT!: <br /> ~ S 2 000 000 <br /> h'L AG:BRE:MTe LIMIT ~nS PER: P~ODLlOTS . COMPJOP AGO . 2 000 000 <br /> POLICY n. I ,nn <br /> ~TOMOBILE LIABILITY COMBINED SINGLE LlMrr s Included in Above <br /> JPetr eCddenl) <br /> I- ANY AUTO <br /> ~ ALL OWNEO AUTOS BODILV INJURV <br /> HDOG21731936 09/01/2004 09/01/2005 (PBrperson) S <br /> SCHeDULED AUTOS <br />A 'x HIRED AuTOS OWNEO AUTOS NOT COVERED <br /> BOOILY INJURV <br /> ~ON-oWNEO Auros {Per accldenl~ S <br /> PROpeRTY i:)AMAGE $ <br /> (Peraccldem) <br /> GA ~GE L1AB1UTY Al1TO ONLY. E!A ACCIDI!!N'T I <br /> - A.NY AUTO NOT COVERED OTMiR THAN EAACC S <br /> AUTO Or.'L'I': AGO S <br /> f----- excess LlA,BIUTY EACH OCCURRENce $ <br /> f----- OCCUR o ClAlltlS MACE AGGRE;:GATE I <br /> f----- NOT COVEREO , <br /> f----- DEDUCTIBLE I <br /> RETENTION is . <br /> WORkERS COMPENSATION AND I we SlAW' I I OtHeR <br /> ~Ul:!t-_..... ......- ..- - . "NOIC'OVERED -- ----- -.._-- .-. 'EL.~C'OENT' -- .. <br /> s <br /> E L OI$EASE. . EA E.MPlOVEE S <br /> E L. Dls~e - POLICY LIMIT I <br /> <br />DESCRIPTION OF OPERATlONS/lOCAT10N9IVEHIClfStEXCl.USIOHS 40ClE:O BY ENDORSEMENT/SPECIAl. PROVISIONS <br /> <br />Provisions of the policy 6pply to the Centerville Lions Club for theIr participation in the 12th Annual Haunted House on October <br />2-23, & 29-30, 2004 (or any other dates during the policy period). <br /> <br />City of Centerville is an additional isnured, but only with respect to liability arising out of the use of premises by the Centerville <br />Lions club and not out of the sole negligence of the said additional insured, <br /> <br />~ TIFI ATE <br /> <br /> <br />ADDITIONAL INSUREDj INSURER LETTER <br /> <br />Stiout,.O ANY OF TfoIe ABOVl! D!'SCRI8ED POUClES BE CANCELED 8EPORE 'l'He <br /> <br />IC Centervllle <br />188v Main Street <br />Centerville. MN 55038 <br /> <br />. EXPlRAT10N DATE lliERBOf, THE ISSUING COMPANY WILt. END~VOR TO MAIL <br />~OAYSWRITTEN NOllCE TO THECERTlF1CAlE HOLDfR NAMED TOTttE Lfli'T. <br />BUT FAILURE" TO MAIL SUCH NOTlC! SHALl., IMPQSI! NO OBUGAnoN OR llA$IUTY <br />Ofl' ANY KINO UPON TM.E COMPANY. ITS AGENTS OR REPRESENTATlVES. <br />AUTHORIZED REPRESE ATI <br /> <br />d.k-6 ~ <br /> <br />John E. Adams, C.P.C.U. <br /> <br />ACORD CORPORATION 1Q8a <br /> <br />** TOTAL PAGE.02 ** <br />