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_---^""s LSBON-1 OP ID:TR <br /> ,a►coRo CERTIFICATE OF LIABILITY INSURANCE DA021281D017 <br /> oti2s�2o17 <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 holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. if SUBROGATION IS WANED,subject to <br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT <br /> NAME: William W.Singer <br /> SingerInsurance Agency PHONNo ExtE <br /> South <br /> 109 South Vine Street Arc 217-543-3737 ac No):217-543-3743 <br /> P.O.Box 18 E-MAIL <br /> Arthur,IL 61911 ADDRESS: <br /> William W.Singer INSURERS AFFORDING COVERAGE NAIC# <br /> INSURER A:Specialty Risk of America <br /> INSURED LSB One,Inc. INSURER B: <br /> 129 S Oakland <br /> Decatur,IL 62521 INSURER C: <br /> INSURER D: <br /> INSURER <br /> - <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 ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> DDL SUBR POLICY EFF ILTR TYPE OF INSURANCE POLICY NUMBER MWODMW MMIDDNYYY LIMITS <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br /> DAMAGE <br /> CLAIMS-MADE E1OCCUR SES(ERER <br /> PREMISES Ea occurrence) $ <br /> MED EXP(Any one person) $ <br /> PERSONAL&ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> POLICY❑JECTPRO F-1LOC PRODUCTS-COMP/OP AGG $ <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED GL LIMIT $ <br /> Ea accident,__, <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED BODILY INJURY(Peraccident) $ <br /> AUTOS AUTOS <br /> FNON-OWNED PROPERTY DAMAGE $ <br /> HIRED AUTOS AUTOS Peracddenl <br /> $ <br /> UMBRELLA UAB HOCCUR EACH OCCURRENCE $ <br /> EXCESS LUIB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATION TH- <br /> AND EMPLOYERS'LIABILI Y YIN STATUTE ER <br /> ANY PROPRIETOR/PARTNERIEXECUTIVEE.L.EACH ACCIDENT $ <br /> OFFICERIMEMBER EXCLUC F-1 N I A <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> A Liquor Liability 10-2011-226 12/28/2016 12/28/2017 Liquor 1,000,00 <br /> Liability <br /> DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space Is required) <br /> Tavern.Coverage in place for Oakwood Block Parties on May 6,June 24,July <br /> 20,August 19,and September 16 of 2017. <br /> CERTIFICATE HOLDER CANCELLATION <br /> DECATUR <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Ci of Decatur THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> City ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Inspections Department <br /> #1 Gary K.Anderson Plaza <br /> Decatur,IL 62523-1196 AUTHORIZED REPRESENTATIVE <br /> ®1988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD <br />