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<br />1- <br /> <br />JAN 13 21211214 1218:47 FR ARTESYN ENGINEERING 612 392 674121 TO 96514298629 <br /> <br />P.12l2/12l2 <br /> <br /> ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MMlDOIYY) <br /> Janual'Y 7, 2004 <br />PROoUCER (630)324-2500 FAX (630)324-2001 ,'" <br /> ONLY AND CONFeRS NO RIGHTS UPON THE CERTIFICATE <br />T.J. Adams Group, LLC ~~,t;P::~~IS CERTIFIC.ATE DOES N~:,.~~';l,9,~NO OR <br />333 E. Butterfield Rd., Suite 500 <br />Lombard, IL 60148 INSURERS AFFORDING COVERAGE <br />, 'NSUROO INSUReR A: ACE American Insurance Comoany <br /> INSURER 8: <br />Centerville Lions Club INSURER c: <br />Minnesota rNSU~eR 0; <br /> INSURER E: <br />COVERAl3E8 <br /> THE POllCI~!!_ OF INSURANCE LISTED BELOW HAVE BEliN ISSUED TO THE INSURED NAMED ABO~=fOR TH.POLICY PERIOD INDICATED. NOTWITHSTANDING <br />ANY ReQUIR6MENT TE~ OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH REsPEcr To WHICH THIS CERTIFICATe MAY e. ISSUED OR <br /> MAY PERTAIN THE INSURANCE AFFORDED BY THE POLlcres OESCRIB!D HEREIN 15 SUBJECT TO ALL THE TERMS. I!XCLUSIONS ANa CONDITIONS OF SUCH <br /> POLiCiES. AGGREGATE LIMITS SHOWN MAY HAVS B..N REDUCED BY PAID CLAIMS. <br /> 1"VPE OF INSURANCE POl.ICY NUMBeR PI"ION~Y !;FFECTlvE. I IN 1.1MIT$ <br />LTR <br /> ~NERAL. LIABILITY ~Cw OCCURRENCE $ 1 oon oar <br /> x COMMI:A:CfAL GENERAL LIABILITY FIRE D.t\MAGE (Atly one fire) S 1 000 000 <br /> I C~AlMSMAtlE -00 CCCU'R - .. .- ..._",. '-- '.._. ... - --~-, ..-. $ l' OOt <br /> M~O E.x~ (Anyon. person) <br />A HDOG1731S36 09/01/2003 09/01/2004 PERSONAL & ADV INJURY $ 1 OO^ ^^;;I <br /> I- GENERAL AGGREGATE $ 2 000 000 <br /> ~N'L AGGREGATE LIMIT APPlIE:s PER: PRODUCTS. COt,fP/OP AeJeJ $ 2000000 <br /> ~ pnr I"'V npFtoJECn LOe <br /> AUTOMOBILE UABlUTY COMBINEC SINGle LIMIT $ Included In Above <br /> "- (Per acddenl) <br /> ANY AUTO <br /> - <br /> - All O:WNEO AUTOS BODll v INJURY I <br /> SCHEOULED AUTOS HDOG1731936 09/01/2003 09/01/2004 (Perpet&on) <br />A X HIRED AUTOS OWNED AUTOS NOT COVERED <br /> eOOIL Y INJURY I <br /> ~ NON.OWNED AUTDS (Pat'CC1derll) <br /> f-'-'- <br /> f- PROPERTY DAMAGe I <br /> (POI'aedd&nll <br /> OA ~GE UABIUTV AlITa ONLY - EA. ACCIP5NT I <br /> ANY AUTO NOT COVERED OTHER THAN EA ACe I <br /> !- AUTO ONl y~ AQQ . . <br /> I;XCES$ LIABILITY to\OH OCCURRENCE . <br /> f- o Cl.AIMS MADE AGGoR'eGAlE <br /> OCCUR . <br /> f- NOT COVERED S <br /> I- oeDucTIBlE . <br /> f- RC1ENTION S I <br /> WORKERS COMPeNSATION AND 8 ",,~~~=:~TI.O:H-;________ <br />.- . eMp..t.OY.E~:r L1ABIYIY _ .-" --.. NO"T-eoVERED-' -- -- ,. - -'-'-- <br /> E L crSEASE. SA EMPLOYEE S <br /> Ii L. D1SEAS&. POLICY LIMIT I <br /> <br />DESCRIPTION OF OPER"TION61l.0CATIONS1VEHICl.E.Sl'CXCLUSIONS ADot:o BY ENDORS.EMENTISPEetAL PROVISIONS <br /> <br />Provisions of the polley apply to the Centerville 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 polioy periOd). <br /> <br />lI.noka County Sheriff and Anoka County are additional insured. but only with respect to liability arising out of the use of premises <br />, lY the Centerville Lions Club and not out of the sole negligence of the said additional insured. <br /> <br />ceRTIFICATE HOLDER I I ADDITIONAL INSURE[): INSIJRER LETTE!t <br /> <br />~noka County Sheriff/Anoka County <br />530 Bunker Lake Blvd. <br />Vldover, MN 55304 <br /> <br />dclu-v e. ~ <br /> <br />1~i;)I"IUJ <br /> <br />ACORD CORPORA.'T'ON 1988 <br /> <br />** TOTAL PAGE.12I2 ** <br />