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,�� LSBON-1 OP ID:TR <br /> ACORO� CERTIFICATE OF LIABILITY INSURANCE DATE(MMfDDMlY1� <br /> `..�� 04/01/2016 <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 /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate hoider is an ADDITIONAL INSURED,the policy(fes)must be endorsed. If SUBROGATION IS WAIVED,subJect to <br /> the terms and conditions of the popcy,certain policies may require an endorsement A statement on this certlficate does not confer rights to the <br /> certiflcate holder in lieu of such endorsement s). <br /> PRODUCER ONTACT <br /> Singerinsurance Agency pHONE Fax <br /> 109 South Vine Street ac wo�: ac wo: <br /> P.O.Box 18 E-Ma�� <br /> Arthur,IL 61911 ��Ss' <br /> William W.Stnger INSURE S AFFOROING COVERAGE NAIC p <br /> iNsur�Ra:Specialty Risk of America <br /> iNsur� LSB One,Inc. iNsu�eg: <br /> 129 S Oakland <br /> Decatur,IL 62521 INSURERC: <br /> INSURER D: <br /> MISURER E: <br /> W SURER 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 PERtOD <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 DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SH01MN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> NSR TypE OF INSURANCE POLICY NUMBER MMlDDlYVYY MNVDDlYYYY ����T$ <br /> LTR <br /> �E��B�� EACHOCCURRENCE § ��OOO�OO <br /> A X COMMERqAL GENEw+L uAeIL17Y 10-2012-4601 1?J28/2015 12128/2016 pREM SE�s E�a opcwRence S 100,00 <br /> CLAIMS-MADE �OCCUR MED EXP(My one perso�) S 1,00 <br /> X PERSONALBADVINJURY S 1,000,00 <br /> GENERALAGGREGATE S Y�OOO�OO <br /> GEN'L AGGREGATE IIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S Z,OOO,OO <br /> POLICY PRa LOC S <br /> AUTOMOBILE LU161LITY MBINED N LE LIM T <br /> Ea acadent 5 <br /> ANY AUTO BODILY INJURY(Per person) S <br /> ALL OWNED SCHEDULED BODILY INJURY(Per ecc(dent) S <br /> AUTOS AUTOS <br /> NON-0WNED PROPERTY DAMA E S <br /> HIREDAUTOS AUTOS PERACCIDENT <br /> a <br /> UMBRELLA UAB p�CUR - EACH OCCURRENCE S <br /> EXCE55 L1A6 CLAIMS-MADE AGGREGATE 5 <br /> DED RETENTION S S <br /> WORKERS COMPENSATION RY IMIT R <br /> AND EMPLOYERS'LIHBILRY Y/N <br /> ANY PROPRIEfORlPARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIOENT $ <br /> OFFICER/MEMBER EXCLUDEO? <br /> (Mandatory In NFQ E.L.DISEASE-EA EMPLOYE 5 <br /> If yes,desaibe urWer <br /> DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S <br /> A �iquor Liability 10-2011-226 12/28l2015 12/28/2016 Liquor 1,000,00 <br /> Liability <br /> DESC W PiION OF OPERAT10N5!LOCATIONS/VENICLES (Amch ACORD 101,Atltlitlonal Ramarka Sehedu�e,H rtare space k required) <br /> Coverage in place for Block Parties on 5/7/16, 6/2/16, 7/9/16, 6/20/16, 6 <br /> 9/17/16. <br /> CERTIFICATE HOLDER CANCELLATION <br /> DECATUR <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> City of Decatur CCORDANCE WITH TH POLICY P OVISIONSE WILL BE DELIVERED IN <br /> Inspections Department <br /> #1 Gary K.Anderson Plaza nunioe�o r��s�Tarne <br /> Decatur,IL 62523-1196 <br /> �3�Q..:-- �--s�%�-�-� <br /> O 1988-2010 ACORD CORPORATION. All rights reserved. <br /> ACORO 25(2010I05) The ACORD name and logo are registered marks of ACORD <br />