2012-71 AUTHORIZING CONSUMPTION OF ALCOHOLIC LIQUOR FOR COMMUNITY EVENT

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/-� FUT1000 OP ID: RT ACORO DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 09/21/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT 217-877-3344 NAME: Rand Taylor J.L.Hubbard Insurance&Bonds PHONE FAx 1090 South Route 51,PO Box 14 217-877-0795 A/C No.Ext):217-87_7-3344 _ A/c�Ne�_217-877-0795 Forsyth,IL 62535-0014 AODR Kevin J.Breheny Ess:rtaylor@jlhubbard.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:National Specialty Insurance 115360 INSURED Decatur Futures Golf INSURER B Classic Inc 403 North Main INSURERC: Decatur,IL 62523 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 I A X COMMERCIAL GENERAL LIABILITY X NSBO89986505 05/16/12 05/16/13 j DAMA E RENTED !� PREMISES Ea ccurr9ncl___$_________100,00 _] CLAIMS-MADE A OCCUR MED EXP(Any one person) $ __ Exclude( PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,00 ill POLICY F1 PRO- LOC $ AUTOMOBILE LIABILITY Ea COMBINED tSINGLE LIMIT $ 1,000,000 A ANY AUTO NSB009985505 05/16/12 05/16/13 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS AUTOS _ X HIRED AUTOS Ix NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident _ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,00 A EXCESS LIAB CLAIMS-MADE NUB144198301 05/16/12 05/16/13 AGGREGATE $ 3,000,00 DED I X I RETENTION$ -0- $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under ! DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I ! DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Re: Pro-Shot Challenger on 10/13/12 City of Decatur is named as additional insured under the General Liability; subject to written contract. CERTIFICATE HOLDER CANCELLATION FUT0004 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Decatur ACCORDANCE WITH THE POLICY PROVISIONS. 1 Gary K Anderson Plaza Decatur,IL 62523 AUTHORIZED REPRESENTATIVE Kevin J.Breheny K8VU111,1 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD