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��^� LSBON-1 OP ID:TR <br /> '4�Ro�' CERTIFICATE OF LIABtLITY INSURANCE DA�t��D�) <br /> 04101/2016 <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 /> REPRESENTA77VE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certiflcate hoider ts an ADDITIONAL INSURED,the policy(ies)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 thts certiflcate does not confer righfs to the <br /> certiflcate holder in lieu of such endorsemen s. <br /> PRODUCER NTACT <br /> Singerinsurance Agency PHONE Fax <br /> 109 South Vtne Street ac no Ext: A/C No: <br /> P.O.Box 18 E-MA L <br /> AKhur,IL 61911 ADDRE33: <br /> William W.Singer INSURE S AFFORDINGCOVERAGE NAICp <br /> iNsu�Ra:S ecialty Risk of America <br /> INSURED LSB One,Inc. WSURER B: <br /> 129 S Oakland <br /> Decatur,IL 62521 u�sur�c: <br /> iwsur�re o� <br /> INSURER E: <br /> INSURER F• <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN(SSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTIMTHSTANDING 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 DESCRIBEO HEREIN IS SUBJECT TO AlL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR <br /> �7R TYPE OF INSURANCE POLICY NUMBER NPMA/DD E� MMIDDIYYYY uMITS <br /> GENERALLIABILITY EACHOCCURRENCE S 'I�OOO�OO <br /> A X COMMERqALGENERALLIABILITY 10-2012-4601 11J28/2015 12/28f2016 pREMISE�S E�ao�rtence a 100,Q�) <br /> CLAIMS-MADE �OCCUR MED EXP(My ane person) S �,00 <br /> X PERSONAL&ADV INJURY S ��OOO,OO <br /> GENERALAGGREOATE S 2,000,00 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: PROOUCTS•CAMPlOP AC,G 5 2,000,00 <br /> POLICV PRa LOC S <br /> AUTOMOBILE LUIBILITY MBINED IN LE LIMIT <br /> Ea acdderN S <br /> ANY AUTO BODILY INJURY(Per person) S <br /> AILOWNED SCHEDULED 80DILYIWURY PeraaWent S <br /> AUT0.S AUTOS � I <br /> HIREDAUTOS NON-0WNED PROPERTYDAMA f <br /> AUTOS PER ACGDENT <br /> E <br /> UMBRELLA W►8 p�CUR � EACH OCCURRENCE S <br /> EXCESS WB CtAIMS-MADE AGGREGATE S <br /> OED RETENTIONS g <br /> WORKERS COMPENSATpN WC STATU- OTH- <br /> AND EMPLOYERS'LIABIIRY Y�N T �RY IMI •R <br /> ANY PROPRIETOR/PARTNEWE%ECUTIVE❑ N�A E.L.EACH ACCIDENT $ <br /> OFFICER/MEMBER EXCLUDED4 <br /> (Mandatory In NfQ E.L.DISEASE-EA EMPLOYE S <br /> If yes,desrnbe urxler <br /> OESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UMIT S <br /> A Liquor Liabflily 10-2011-226 12128l2015 12/28/2016 Liquor 1,000,00 <br /> Liabilfty <br /> DESCWPTION OF OPERATIONS!LOCATIONS/VEH�CLES(Attach ACORD 107,Additlonal Remarka Sched�de,If mwe spaee Is nquhad) <br /> Coverage in place for Block Parties on 5/7/16, 6/2/16, 7/9/16, 8/20/16, 6 <br /> 9/17/16. <br /> CERTIFICATE HOLDER CANCELLATION <br /> DECATUR <br /> SHOULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> City of Decatur YNE EXPIRATION DATE THEREOf, NOTiCE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Inspections Department <br /> #1 Gary K.Anderson Plaza <br /> Decatur,IL 62523-1196 AUTHOR¢ED REPRESENTATNE <br /> �.J�-- �--5�-- <br /> O 1988-2010 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD <br />