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� , <br /> c�ard � . ,- . . . . � . .. , , <br /> ,. . , , .. . ... , .. ,� ,� <br /> NAMf XNO AO�RESS OF AGENCY <br /> COMPANIES AFFORDING COVERAGES <br /> Mary C. Biennan <br /> 613 South 9th COMPANV <br /> LETTER A Illinois National Insurance Co. <br /> P.O. Box 297 <br /> Springfield, Illinois 62705 ETfER Y p <br /> NAME ANO AOORESS OF INSURED <br /> COMPANY � <br /> Triple G. Oil Co. Ltd. LETTER <br /> P.O. BOX G 3 I COMPANY D <br /> Mundelien, Illinois 60060 LETTER <br /> coMPnNr E <br /> LETTER <br /> This is to cartify that policies of inwranee listed below have been issued to the insured named above and are in force at this time. Notwithstanding any requi►eme�t,term or condition <br /> of any co�tract or other doeument with respect to which this certificate may be issued or may pertain,the inwrance afforded by the policies described herein is subject to all the <br /> terms,exdusions and conditions of wch poliaes. <br /> COMPANV ��i�y Limits o Liabili in ousan a <br /> LETTER n'�Of INSURANCE POIICV NUMBER �(p�RATION DATE EACH AGGREGATE <br /> OCCURRENCE <br /> GENERAL LIABILITY <br /> BODILY INJURV 5 ; <br /> ❑COMPREHENSIVE FORM <br /> ❑PREMISES-0PERATIONS PROPERTY DAMAGE S = <br /> �ExH O�S DN ANO COLLAPSE <br /> ❑UNDERGROUNO HAZARD <br /> �PRODUCTS/COMPIETED <br /> ❑ OPERATIONS HAZARD BOOILY INJURY AND <br /> CONTRACTUAI INSURANCE PROPERTY DAMA6E f f <br /> � BROAD FORM PRpPEF�TY COMBINED <br /> DAMAGE <br /> ❑ INDEPENOENT CONTRACTORS <br /> ❑PERSONAL INJURY PERSONAL INJURY E <br /> AUTOMOBILE UABILITY eooi�v iN�uRr E <br /> (EACH PERSON) <br /> ❑ COMPREHENSIVE FORM BODIIY INJURY ; <br /> ❑OwNED (EACH ACCIDENn <br /> ❑ HIRED PROPERTY DAMAGE f <br /> BOOIIY INJURY AND <br /> NON-0WNED PROPERTY DAMA6E f <br /> COMBINED <br /> excEss uaeamr <br /> BOOILY INJURY AND <br /> ❑ UMBRELLA FORM E f <br /> PROPERfY DAMAGE <br /> ❑ OTHERTHAN UMBRELLA COM8INED <br /> fORM � <br /> WORKERS'COMPENSATION STATUTORY <br /> and <br /> EMPLOYERS'LIABILITY s <br /> (EPIC H ACCIOENT) <br /> OTHER <br /> A Blanket Surety Bo d 38-14-60 3/26/83 10,000 Oil Well Completion Bon <br /> UESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES <br /> Cancellatbn: Should any of the above described policies be cancelled before the expiration date thereof, the issuing com- <br /> pany will endeavo� to mail days written notice to the. below named certificate holder, but failure to <br /> mail such notice shall impose no obtigation or liability of any kind upon#he company. <br /> NAME ANO ADORESS OF CERTIFICATE HOlOER <br /> �ATE ISSUED: <br /> City of Decatur � <br /> # I Civ1c Center Plaza �� ��T <br /> Decatur, l I I i noi s 62523 �'�`"`" � � <br /> AUTHORIZED REPRESENTATIVE <br /> ACORD 25(1•79) <br />