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ACORD CERTIFICATE OF LIABILITY INSURANCE PRODUCER (952)893 -9218 FAX (952)893 -9402 CORPORATE 4 INS AGENCY, INC. 7220 METRO BOULEVARD EDINA, MN 55439 -2133 `-'INSURED DATE (MM/DDIYYYY) 12/05/2003 THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT FICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POIY1C_E$ BELOW. INSURERS AFFORDING COVERAGE NAIC # Circle Pines - Lexington Lions Club PO Box 13 Circle Pines, MN 55014 INSURER A: Lexington Insurance INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES THE ANY MAY POLICIES. POLICIES REQUIREMENT, PERTAIN, OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDfNI TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR D01, TYPE Op INSURANCE POLICY NUMBER POLICY EFFECTIVE AGTF MIADP'Yt POLICY EXPIRATION OAT [MMIRIIIW) OMITS EACH OCCURRENCE $ GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PRFMISF3 (Fn evruronrp) $ CLAIMS MADE n OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMITAPPUES PER: PRODUCTS • COMP /OP AGG $ POLICY n JECT I LOC AUTOMOBILE — LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS Tt I It`n�)r,AI�CE IS c,: rrl((VN SOTA SURPLUS AG . '�'I-s,E INSURER fS 1 �' 1 ,( +,LS INSURER BLT LICENSED BY THE S1 E C)F ,NSOLVENCY, CASEEN r Ij f .o_ f 0"i..r /J\(TFFr) SURPLUS LINES TAX ISSUED PURSUA.I�IT LINES I� AN ELIGIBLE lS NOT Gi ATE OF MENNESOTA. PAYMENT TO SU1RANCE _I.+�PLUS HE}3V111SE IN OF CLAIMS COMBINED SINGLE LIMIT (Ea accident) $ _ BODILY person)RY $ _� BODILY eracciNJURY (Per acCidenI) $ — PROPERTY DAMAGE (Per accident) AUTO ONLY - EA ACCIDENT $ $ GARAGE LIABILITY ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS 7 /UMBRELLA UABILTY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ $ WORKERS COMPENSATION AND EMPLOYERS UASIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below 1 1) 1 TORY STATU- I. IOER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A quor Liability +' /31 /2003 10/31/2004 See Below D €SCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS AODED BY ENDORSEMENT / SPECIAL PROVISIONS Limits: $10,000 PD each occurrence /$300,000 BI each person and each occurrence /$300,000 loss of support each person and each occurrence /$600,000 aggregate limit per club. \"'' City of Lino Lakes Lino Lakes, MN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, SUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR RE #RESENTATWES. ACORD 25 (2001/08) AUTHORIZED REPRESENTATIVE Jane Johnson /MARYB 12A,tx— g£312444crY0 :.ACORD CORPORATION 1988