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<br />JAN 13 2004 08:47 FR ARTESYN ENGINEERING 612 392 6740 TO 96514298629 <br /> <br />P.02/02 <br /> <br /> ACORD CERTIFICATE OF LIABILITY INSURANCE OATE(MMlDO/YY') , <br /> - Januarv 7, 2004 <br />PRODUCER (630)324 2500 FAX (630)324-2501 THIS ".,~ <br />T.J. Adams Group, LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br /> HOLDER. THIS CERTIFICATE DOES NOT ~r;,~~ 8<TENO OR <br />333 E. Butterfield Rd., Suite 500 A" """'" <br />Lombard, IL 60148 INSURERS AFFORDING COVERAGE <br /> INSUReR A: ACE American Insurance Comoanv <br /> INSURER B: <br />Centerville Lions Club INSURER c: <br />Minnesota INSURER 0; <br /> INSURER 1;: <br />COVERAl>t:,; <br /> THE POLICIES OF INSURANCE lISTeO BeLOW HAve B~!!,!!~SUEO TO THE INSURm NAMED ABOVE FOR TH',,~".LICY PERIOD INDICATED. NOTWITHSTANDING <br /> AW( REQUIREMENT TEIlM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTlFICATE MAY eE ISSUED OR <br /> MAY PERTAIN THE INSURANCE AFFOROED 6Y THE FOLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, exCLUSIONS AND CONDITIONS OF SUCH <br /> POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />'llR TYPE OF INSURANCE POLICY NUMBER I Pl"\~~~V e::FFECTlv ~ LIMITS <br /> GENERAl. LJABlUTY EACH OCCURR5NC! . 1 ODD DOC <br /> - FIRE DAMAGE tAil)' one nre) I 1 000 000 <br /> X COMMEA:CIAI. GENERAL LIABILITY <br /> I CLAIMS MADE -0 OCGU'~ - ._ ._ .___n.. '-- '..-. ... - --.-- . ".-. S <br /> MEa ~p (Any on.lll per'$ot\) 1 DOC <br />A HDOG1731936 09/01/2003 09/01/2004 PERSONAL. & ADV INJURY $ 100 <br /> - GENERAL AGGREGATE S 2 000 000 <br /> ~N"L AGGRe:OATe LIMIT APPLIes PER: PROOIJCTS . COMPfOP AG3 I 2 OOO~OOO <br /> I P~""V npROJECn loe <br /> AUTOMOBILE UA&JUTY COMBrNEIl SINGL.E LIMIT S Included in Above <br /> - ANY AUTO (Per Bccldenl) <br /> - ALL OWNED AUTOS <br /> BDDIL Y INJURY $ <br /> t- SCHEDULEC A.UTo~ HDOG1731936 09/01/2003 09/01/2004 {Perperaonl <br />A 'x HIR&C AUTOS OWNED AUTOS NOT COVERED <br /> MOIL'f INJURY <br /> '1( NON-OWN~D AUTOS (Pat .~Id~nl) $ <br /> -= <br /> "- PROPERTY DAMAGe I <br /> (ParaC:~d6'ntl <br /> 0. lAGE UABIUTY AUTO ONLY - EA ACClOeNT I <br /> ANY A.UTO NOT COVERED OTHER THAN EA ACC I <br /> <- AUTO ONLY: AGG I <br /> eXCESS LtABILSTY EAOH OCCURRENCE I <br /> f- o CLAIMS MADe AGGREGATE <br /> OCCUR I <br /> f- NOT COVERED I <br /> I- OEDUCTJBLE $ <br /> I- RE:1"SNTlON $ $ <br /> WORKERS COMPENSATION AND I . I I OTHER <br />,-, eM~(.O,(.E~~.: trAStUTY -. No-T-e-oVERED - - .. - ,., .". ~~~NT "-'- S .------... <br /> e L DISEASE - ~ EMPLOYEE S <br /> E L. DISEASE. POLICY LIMIT S <br /> <br />DESCRIPTION OF OPERATIONSILOCATlDNSIVEHICLESIEXCLUSIONS ADOED BY ENDORSEMENT/SPECIAL PROVISIONS <br /> <br />Provisions of the policy apply to the Centervi/le Lions Club for their participation in an Ice FiShing Contest, located at Centerville <br />_ake, on February 7, 2004 (or any other dates during the policy period). <br /> <br />","oka County Sheriff and Anoka County are additional insured, but only with respect to liability ariSing out of the use of premises <br />,y the Centerville Lions Club and not out of the sole negligence of the said additional insured. <br /> <br />(;f:RTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER <br /> <br />~noka County Sheriff/Anoke County <br />530 Bunker Lake Blvd. <br />\ndover, MN 55304 <br /> <br />-. ,,,.,, <br /> <br />ACORD CORPORATION 19aB <br /> <br />** TOTAL PAGE.02 ** <br />