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10/12/2012 11:35 2175433743 SINGER INSURANCE PAGE 02 <br /> LSBON-1 OP ID'TR <br /> OATE(MMIDOMYYY) <br /> A RRA CERTIFICATE OF LIABILITY INSURANCE 10/12/12 <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(les)must be endorsed. If SUBROGATION 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 endorsemen s. <br /> -CONTACT <br /> PRODUCER Phone: <br /> 217-543-3737 NAME: <br /> ,• _ (A_ACSinger Insurance Agency Fax:217-543-3743 PHONNE0,ER):__10South Vine Street �MAIL <br /> _ <br /> P.O.BOX 1$ _ADDRES9:• — <br /> Arthur,IL 81911 INSURER(8)AFFORDING COVERAGE _ NAIC <br /> William W.Singer - - <br /> INSURER A:Specialty Risk of America - <br /> INSURED LSS One, Inc. INSURER B_ <br /> 129 S Oakland INSURERC: <br /> Decatur,IL 62521 INsuRER o <br /> INSURER 9: <br /> INSURER F <br /> COVERAGES- CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> _ _.. <br /> no" <br /> I` R TYPE OF INSURANCE POLICY NUMBER 1gM%t7 F 1 ML/OWrVYP LIMITS <br /> GENERAL LIACILITY I EACH OCCURRENCE 8 - 1,000,00 <br /> m4�T6inimn <br /> A X COMMERCIAL GENERAL LIABILITY X 280166 12/28111 12/28/12 �PREMI ES(Ec.ocyurrence).., 3 101,D <br /> CLAIMS-MADE L I OCCUR MED EAP(Any are person) S 1,00 <br /> PERSONAL a ADV INJURY E 1,000,00 <br /> GENERAL AGGREGATE S 2,000,00 <br /> GEN'L AGGREC�ATF-LIMIT APPLIES PER: PRODUCTS-COI PJOP AGR`S 2,000,D <br /> PDI ICV <br /> PRO- <br /> jFI;T F-1 LOC _ S — <br /> COMBINED&INGLE LIMIT <br /> AUTOMOBILE LIAeILIrY I I (E i,PcFIdMM)_-. �_. .. .. <br /> ANY AUTO BODILY INJURY(Per Cason) S <br /> ALL OWNED + SCHEDULED BODILY INJURY(Por�CGSdenl) S <br /> PRS r., 1W <br /> AUTOS 4 NON OWNED Par,efi ant 3 <br /> HIRED AUTOS AUTOS (...:_�_)...-. -...—_r•_. <br /> s <br /> UMBRELLA LIAR OCCUR t;ACH OCCURRENCE _ It <br /> EXCESS LMB _ CLAIM$MADE X AGGRF-GATE <br /> DEORETENTIONSS <br /> WORKERS COMPENSATION TO Y,LIAIJLI IOep_ <br /> AND QIHPLOYERS'LIABILITr ER <br /> Y1 E.L.EACH ACCIDENT <br /> ANY PROPRISTOR/PARTNERXECUTIVE ( E <br /> OFFICER(MEMBER EKCLUDEO? L N 1 A E.L.DISEASE_-EA EMPLOYEE S <br /> (Mandalary Irl NH) •• -' <br /> It yyea dnfcAbe UnMr E.L.DISEASE-POLICY LIMIT S <br /> DEA RIPMON OF OPERATIONSbelow <br /> A Liquor Liability 10-2011-226 12/26/11 ' 12128/12 Each CC 1,000,00 <br /> Aggregate 1,000,0 <br /> DESCRIPTION OF OPERATIONS,LOCATIONS I VENICLFS(A/tach ACORD 101,Adadonel Remarks Schedule,it more apace IS RqulnO) <br /> Tavern- Oakwood Association Street Festival on Oct. 20 <br /> CERTIFICATE HOLDER CANCELLATION <br /> DECATUR <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> City of Decatur ACCORDANCE WITH THE POLICY PROVISION$ <br /> 01 Gary K.Anderson Plaza <br /> Decatur,IL$2523-1196 AUTHORIZF0 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 />