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09/15I2015 09:49 2175433743 SINGER INSURANCE PAGE 02 <br /> L,SeON-1 4P ID:KP <br /> A��� oare�nnNlDomvrl <br /> ��RYtFic�TE a� �iaB��.�-�r �r�su�NCE o��,�0�5 <br /> TH[S CERTIFICAT6 IS 1SSUED AS A MA7T�R OF INFdRMAT14N ONLY AN� CON�ERS NO RIGHTS UP4N TFIE C�RTIFICATE HOLDER.TIiIS <br /> CERTIFICATE DOES NQT AFFIRMATNELY OR MEGATIVELY AMEND, EXTEND OR ALTER TNE COV�RAGE AFFORDflD 6Y THE POLICIES <br /> BELOW. TliIS CERTIFICATE GF iNSURANCE DOES NOT CON3TITU7E A CONTRACT BE7WEEN THE ISSUING INSURER(S), AUTHORtZED <br /> REPRESENTAtIVE OR PRdDUCER,ANO THE CERTIFICATE HOLDER. <br /> IMPORTANT: !f the certificate holdeC is an AT�DITIONAL INSURED,!he poliCylies)must be endorsed. if SUBROGATION �S WAIVED,subjeCt to <br /> the betn+s and conditfans of the polieY,eertain pol�cies may require an endorSemenl. A 9tatam�nt on thls ce�tificate does not confer r�ghts ta tl�e <br /> certifiCale halder 9n Neu of such end4rsemerrt s. �ACT <br /> PRODUCER ,�„M�; Y Williarn W.Singer ,_ <br /> Slnger Insurance Agency PHONfi ��x_r�qg�73� �uC,No}:Z17'S43-3743 <br /> 109 5outh Vine Street A�w°•�l" .� <br /> P.o.soX�a ���`--: - <br /> Arthur,IL 61911 INSURfiR 8 ARlORDINO COYHRAOfi , _ NhIC� <br /> Williarn W.5islgar ' <br /> iNsuaER a:Specia Risk of Amerfca . . . <br /> INSUR�O LSB On�,I11C. INSURER 8� , •- <br /> 129 S Oakla�d n�suReRc,:. � <br /> pecatur,�L EZSY� IN8UFER�: _• �- - <br /> INSYR�R E: , . • <br /> INSURER F: <br /> C01/ERAGES CER7iFICATE NUMg�R: RE1fIS1QN NUMBER: <br /> THI5 IS 70 CERTIFY THAT ThIE P�LICIES OF INSURANCE LISTED�ELOW HAVE BEEhI ISSUED TO THE INSURED NAMEo ABOVE FOR 7HE POLICY PER�QD <br /> IN�1CAfEo. NOTWITNSTANOING ANY REOUIREMENT, TERM OR COND�TtON OP ANY CONTRACT OR OTHER oOCUMEf�T WITH RESPEC7 TO WHICH THIS <br /> CER7IFICATE MAY BE ISSUED PR MAY PERTAIN, THE IN9URANCE AFFOROED BY THE POUCIES DESCRIBED HER�IN {5 SU9JECT Tp ALL THE TERMS, <br /> E%CLUSIONS AND CONDffIONS OF SUCH PQ�ICIES.L1MIT5 SHOWN MAY HAVE BEEN REDUCED 9Y PAID CLAIhI15. , <br /> LTR TwPfl OF Il19Ua4NCE POLICY MYMBRR �p 6FF fiXP �g <br /> A X OOMMERCN6 AEN�L LIABILm' ERCH OCCURRENCE S 1�OOO�OO <br /> 12J2812014 i�lZel2075 ��� 70000 <br /> CWMS-M,4oE �4CCUR X 10-2012�6D7 PREMI.S.E.S [e occurrmxm � ' <br /> M�D EXP(Arry ona po'ser+) R 1,Oa <br /> ' PERBONAL&Aov fNJURY S 2�ODO,O6 <br /> GLHE�AGGREcarE a Y,DOO,OO <br /> G£N'L AGGRE6ATF,LIM1TApPLIES PER: � 2�000�00 <br /> pRp_ PROOUCT3-COMPIDP AG6 S <br /> Po�,CY n JECT � �o� � s <br /> OTHER' COMBIfiEQ SINGLE LIMI�T g <br /> ALJTONOBILE LIAeILITY -�Ew°����- ' <br /> 6DDI61'INJURT(Par pa��) 1 <br /> ANY AUTO <br /> � ALLOWN6D �� SCHEDULE4 BODfLrINJURY(PereccWan!) S <br /> �7�pg A�JTOS PROP OMIAOE �5 <br /> NON-OWNED ewraeeftlanp, _ . <br /> HIRED AUTOS AVTpS g <br /> EACH OCCURRENCE S <br /> UMBRELLA lIR9 � OCCUR ' '� <br /> EXCESS LtA6 CLAIMS-N1�4DE ' AGGREG#A� $ .. <br /> . S <br /> p�o RE�NnONS orri- <br /> WORKERS�MPEMBarON STp`T�TE �� <br /> pND EMPL07��'WBILRY y�N E.L.EACH ACCIDENI' S <br /> ANY PROPRI�TOR/PAFiTNER16XECU'hVF. � N I R <br /> pFF10ERIMEMBER E%CLUbEl7? E.L.DISER9E-EA EMPLDYEE S, . <br /> (MnndatOry in NH) <br /> If ye�a da=tA�e under E��.DISEA9E-POLICY UMIT a <br /> DE5G�RIPTION OF OP �T�aNS be�ow 12128Ix044 12l281x015 1,8DO,d0 <br /> q Liquor Llabilily K �90•2011-228 <br /> OfiB�aPT10N OF OPERATION$���AT10N61 Y�NICLES{ACARD 7 di,AAtllHena)R.maflm BM�duk,++ary b•�'°hW H n»n■p■b+Is nqul*�dl <br /> Coverage in plac�for Bik$NIght everit held on�'hursday,S9ptember 24,2015 <br /> from 4:Od pm to 10:00 pm at the 100 Black of Soutti Oak�and Ave. <br /> CERTIFICATE HOLI�ER CANCELLATiON <br /> CIDE001 <br /> SHOULa ANY Of TH��4BOVE D�SCRIBED POI.�CIES BE CANCELLEO BEFCRE <br /> THE ExPIRA'fION Dl4T� 'niER�OF, N0710E WILL BE DEWERED IN <br /> City Qf Decatur ACCORDANCE WRN 71iE PGLICY PROVISIONS, <br /> 1 Gary K.Anderson Plaza <br /> '�@Ca�JI'�IL 6�523-7 496 Au7HOR1ZE0 R6pRoseNTATNE <br /> t,.��X�-- ,..�S't.'`��. <br /> ` �1988•2014 ACORD GQRPORATIf�N. All rights raservad. <br /> ACORD 25(2014lQ�) The ACORD name and logo are registered marks of ACORD <br />