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LSBON-1 OP ID:TR <br /> CERTIFICATE OF LIABILITY INSURAN 03/31/20 E DATE(M1/20 5 <br /> 15 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If UBROGATION IS WAIVED, subject to <br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT <br /> SinSinger Insurance Agency NAME: <br /> g g Y PHONE FAX <br /> 109 South Vine Street A/C No.Ext): (AIC, <br /> A/C No): <br /> P.O.Box 18 E-MAIL <br /> Arthur,IL 61911 ADDRESS: <br /> William W.Singer INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURER A:Specialty Risk of America <br /> INSURED LSB One,Inc. INSURER B: <br /> 129 S Oakland <br /> Decatur, IL 62521 INSURER C <br /> INSURER D: <br /> INSURER E: <br /> INSURER F <br /> COVERAGES CERTIFICATE NUMBER: REI FISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N AMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOC JMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED H REIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSRLTR TYPE OF INSURANCE POLICY NUMBER MM DCD//YYYY MY EFF M/LDDY/YEYYY LIMITS <br /> LTR <br /> GENERAL LIABILITY EAC H OCCURRENCE $ 1,000,00 <br /> A X COMMERCIAL GENERAL LIABILITY 10-2012-4601 12128/2014 12/28/2015 PREMISES Ea occurrence $ 100,00 <br /> CLAIMS-MADE EKOCCUR ME EXP(Any one person) $ 1,00 <br /> X PEF SONAL&ADV INJURY $ 1,000,00 <br /> GEIJERALAGGREGATE $ 2,000,00 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: PR DUCTS-COMP/OP AGG $ 2,000,00 <br /> POLICY PRO- LOC $ <br /> AUTOMOBILE LIABILITY CO IBINED SINGLE LIMIT <br /> Ea ccident <br /> ANY AUTO BO ILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS AUTOS <br /> NED PR PERTY DAMAGE <br /> HIRED AUTOS AUUTOSTOS <br /> NPE ACCIDENT $ <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB Ll CLAIMS-MADE AGGREGATE $ <br /> DED I I RETENTION $ <br /> WORKERS COMPENSATION WC STATU- OTH- <br /> AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVEâť‘ E.L.EACH ACCIDENT $ <br /> OFFICER/MEMBER EXCLUDED? N/A <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ <br /> A Liquor Liability 10-2011-226 12/28/2014 12/28/2015 Liquor 1,000,00 <br /> Liability <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) <br /> Coverage in place for Block Parties on 5/9/15, 7/11/15, 8/22/15, & 9/19/15. <br /> CERTIFICATE HOLDER CANCELLATION <br /> DECATUR <br /> SHOULD ANY OF THE ABOVE DESC IBED POLICIES BE CANCELLED BEFORE <br /> Cit of Decatur THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> City ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Inspections Department <br /> #1 Gary K.Anderson Plaza <br /> Decatur, IL 62523-1196 AUTHORIZED REPRESENTATIVE <br /> ©1988-2010 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD <br />