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<br />ACORDCERTlFICATEUF LIABILITY INSURANCE II M1E(M\.tI:DY\') <br />... December 6, 2005 <br />"RODUCER (630}324-2500 FAX (630}324-2501 ON..Y /fIrllDca.lFERSNORlGHTSUPONltEU::Kllt"LiAlE <br />T. J. Adams Group, a HOb Rogal & Hobbs Company HCl..J:ER.1HISU::KllHCAlEDOESNOT AM:NDEX'fEND~ <br />333 E. Butterfield Rd., Suite 500 <br />lombard, Il60148 NSl.H:RSAFfCR)NGCOv'ERAGE <br />MilJRB) 1NSl.RERA: PCEp,j.IBfIcal.1nsLBanca <br /> INSURERS: <br />:entervllle lions Club 1NSl.RERC: <br />lIinnesota NiURERD: <br /> NiURERE: <br /> <br />lHEPOUCIESOF USTED BELOW HAVE 'luTHE ABOVE rut( ~INDICATED. ~ <br />ANY REQUlREMENTTERM OR CONDITION OF ANY CONTRACT OR OTHERDOCUMENTWITl-I RESPECT TO WHICH THIS U::K1~a.;ATE MAY BE ISSUED OR <br />MAYPERTAN1HE~BVlHEPC1CESI.JI::Z:iUQ:ICUH8BIIISSlJB.ECT1l)Al.L 11-E1ERMS.1.=Xa I /SfOI\ISAND~a:SUCH <br />POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAlDa..AIMS. <br />3R 'NPECFIII5lRAN:E I fQ.CYN.MI5R - EACHOCCURRENCE LIMITS <br /> GENERAL LIABIU1Y I $ 1 <br /> ~ <XMBOAI G8ER'L.lWlIJ1Y FR:DQNlGE~_Ire) $ 1 (YYUlOO <br /> I ~MADE m a:clR ~ $ -UXXl <br /> NEDBCP~_pIlIIiD1) <br />A t-IlOO21731mB 09f01/2005 O9I01l2OO6 PERSONAl&NN INJURY $ 1 000 000 <br /> - G9ERALAGGREG6.1E $ 2.000 000 <br /> ""GEM.AGGREGP.1E UMIT APPI..IES PER: PRODUCIS-OOMAtP /100 S ZOOCUlOO <br /> I......~n. nLoc <br /> AUTOMOBILE LIABIIJTY a:MiNDSN3lELMT S IrdJded InNxNe <br /> - (Per 8lllifenl) <br /> IWV AUTO <br /> - <br /> ALLONNEDAUTOS BODD..YINJURY <br /> - HDOG21731mB 00t)'Iaxl5 0901fn)6 (Perpen;on) S <br /> SOIEDLI.EDAUTOS <br />A X HIREOAUTOS OI\tfi)Al.JTCSN:JrCOt'8B) <br /> BCDII..Y INJURY <br /> ~ (Per8lll:lderl) s <br /> NCl'KJWNB)AIJTOS <br /> f-- <br /> f-- t"IiUt'I::tCl T DAMAGE S <br /> (Per1UtlBnl) <br /> LIABIU1Y AUTO(JIII.Y -EAAOODENT $ <br /> IWV A\IfO N:Jr~ <JIIomnfAN BV\OC $ <br /> - AUTO (JIII.Y: <br /> /IGJ S <br /> EXCESS LIABlUJY EACH OCCURRENCE $ <br /> - OaAlMSMADE <br /> a:clR AGGREGAlE S <br /> - NOT COVERED $ <br /> - <br /> IEDUCIlII.E S <br /> - <br /> RE1ENTICJ'\I$ $ <br /> WORKERS COMPENSATlotI AND I WCSTAJU. I I OTHER <br />.- EMPLOYERS" UA8lL1TY______ - NOTc::x>'VERED . -- -- EL EACH/ICCIDENT $-- - -- -~--- <br /> ELDIS6ASE-EA S <br /> E L DIl:EASE-PClJCVUMIT S <br />DEScRlPTlotI OF OPERATION8ILOCATIONSIVEHlCLESlEXCWSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS <br />:Jrovlsions of the policy apply to the Centerville lions Club for their participation in the Ice Fishing Contest on February 10-12, <br />!006 or any other dates durit1g'1f1epolrcy~perlod. -- <br />rile City of Centervllle and Moka County Sheriff's Office are additional insured, but ONLY with respect to liabOity arising out of the <br />Jse of Premises by the Centerville lions Club and not out of the sole negligence of the said additional Insured. <br />:JROVISIONS OF THE POLICY DO NOT APPLY TO THE SAlE OR SERVING OF AlCOHOLIC BEVERAGES. <br />_...u._JE I I ADDITIONAL INSURED; INSURER LETTER <br /> SHOULD AN'( OF TIlE ABOVE! ~cn POLICIES BE CANCELED BEFORE TIlE <br /> EllPIRATlON DATE 1HE!REOF. TIlE ISSUING COIIPANYWILL ENDEAVOR TO MAIL <br />:::Ity of Centervllle, .JQ.... DAYS WRITTEN NOTICE TO TIlE CERTlRCATE HOLDER NAMED TO THE LEFT. <br />~oka County Sheriff's Office, BU1' FAIWRE TO MAIL SUCH NOlICESHAU.1MPOSE NO OBUGATIotI OR LIABIIJTY <br /> OF ANY KIND UPON TIlE COMPANY. rrs AGENTS OR Kl:l"Kt:St:NTATIVES. <br />IIIlnnesota ATJve _/'.1._, F. /!'/nLAAA, <br /> Tft1... 'D A..:J_ ,.. D ,.. " <br /> <br />31 <br />