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*46,& <br /> � . Policy Number: <br /> XOM 21-02 <br /> NAME AND ADDRESS OF AGENCY COMPANY <br /> ^, MENDEL S. KALIFF INSURANCE Lloyd' s U.S. <br /> 70 N.E. Loop 410, Suite 440 Effective an 1,19 <br /> San Antonio, Texas 78216 Expires ❑{ 12:01 am ❑ Noon Jan 1,19 88 <br /> ❑This binder is issued to extend coverage in the above named <br /> company per expiring policy M <br /> /except as notes below) <br /> NAME AND MAILING ADDRESS OF INSURED Description of Operation/Vehicles/Property <br /> AMERICAN BICYCLE ASSOCIATION, INC. <br /> 8620 N. New Braunfels, ##311 <br /> San Antonio, Texas 78217 <br /> Type and Location of Property Coverage/Perils/Forms Amt of Insurance Ded. <br /> P <br /> R <br /> 0 <br /> P <br /> E <br /> R <br /> T <br /> Y <br /> Type of Insurance Coverage/Forms Limits of Liability <br /> Each Occurrence Aggregate <br /> L Comprehensive Bodily Injury $ $ <br /> 1 ❑ Scheduled Form prehensive Form <br /> Premises/Operations <br /> Products/Completed Operations Property Damage $ $ <br /> y Inj <br /> ury ur & <br /> I �Contractual I y <br /> T {Other (specify below) Property Damage $ 1,000,00 $ None <br /> Y ❑ Combined <br /> TyMed.Pay. $ Per $ Per <br /> Personal injury Person Accident ❑ A ❑ B EI C Personal Injury $ Incl. <br /> Limits of Liability <br /> A ❑ Liability El Non-ownedEl Hired Bodily Injury(Each Person) $ <br /> T ❑ Comprehensive-Deductible $ Bodily Injury(Each Accident) $ <br /> 0 ❑ Collision-Deductible $ <br /> M <br /> 0 ❑ Medical Payments $ Property Damage $ <br /> B <br /> I ❑ Uninsured Motorist $ <br /> L ❑ No Fault (specify): Bodily Injury K Property Damage <br /> E <br /> ❑ Other (specify): Combined $ <br /> ❑ WORKERS' COMPENSATION — Statutory Limits (specify states below) ❑ EMPLOYERS' LIABILITY — Limit $ <br /> SPECIAL CONDITIONS/OTHER COVERAGES <br /> Includes $1 Million Participant Liability <br /> Participant Accidental Death $3,000; Excess Medical $3,000 with $200 Ded. <br /> 30 Day Notice Prior to Cancellation <br /> NAME AND ADDRESS OF ❑ MORTGAGEE ❑ LOSS PAYEE Lr� ADD'L INSURED <br /> �{ <br /> MENDEL S. KALIFF <br /> Lino Lakes BMX #1059 LOAN NUMBER <br /> David Rhode <br /> 2816 Blackstone <br /> St . Louis Park, MN 55416 <br /> City of Lino Lakes , its Officers By: 1/2 7 <br /> and Employees Signature of AuthqlileVRepresentative Date <br /> AcoRD 75 01/77-0 <br />