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ACORD CERTIFICATE OF LIABILITY INSURANCE PRODUCER (942)893 -9218 FAX (952)893 -9402 CORPORATE 4 INS AGENCY, INC. 220 METRO BOULEVARD INA, MN 55439 -2133 . '""INSURED Circle Pines - Lexington Lions Club PO Box 13 Circle Pines, MN 55014 GATE (MMIDDIYYYY) 12/0S/2003 THIS CERTIFICATE 1S 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 AFFOR ED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # NsURERA: Lexington Insurance INSURER B: ENSURER C: INSURER 0: INSURER E: COVERAGES THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINI ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT'TO WHICH THIS CEiiTIFICATE MAY SE Issl IMn OR MAY POLICIES. PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT 70 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INTSRR Jam.-._ Hann TYPE OP INSURANCE • POLICY NUMBER POLICY EFFECTIVE faTnm, nryv% POLICY EXPIRATIONT osro)esvrnnrn LiNpTS GENERAL LIABILITY COMMERCIAL GENERAL LIABILTY T INSURANCE 1S Tr.'" MINNESOTA SURPLUS ACT. THE INSURER 13 LINES INSURER BUT LICENSED BY THE SrAcE CASE OF INSOLVENCY, I MrrFF[) �}S ¢• fr. UN ES TAX , ISSUED PURSUANT LINES Bs AN ELIGIBLE IS NOT OTHERWISE OF MINNESOTA. PAYMENT . TO SURAN . E SURPLUS IN OF CLAIMS EACH OCCURRENCE $ DAMAGE TO RENTED PRPML4P4 Pen $ 1 CLAIMS MADE OCCUR MED EXP (Any one person) $ • PERSONAL ILADVINJURY 1 `- GENERAL AGGREGATE $ GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS. COMP/OP AGG $ AUTOMOENJ> -..- Poucv 1 1jECT n LOC LIABILITY ANY AUTO ALL OWNED AIlTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED occident) INGLE LIMIT $ • BODILY INJURY (Per person) _ —_ BODILY INJURY (Perecddenl) $ PROPERTY DAMAGE (Per accident) AUTO ONLY - EA ACCIDENT $ $ ANY AUTO GARAGEUABILITY EA ACC $ SURPLUS. OTHER THAN AUTO ONLY: AGO $ EXCESS/UMBRELLA UAB$UTY EACH OCCURRENCE $ OCCUR ■ CLAIMS MADE AGGREGATE $ • DEDUCTIBLE •RETENTION $ •S $ • $ WORKERS COMPENSATION AND E1WPLOYBRS' UASWTY • AMY. PROPRIETOR/PARTNER/ps•$ 7Na' OFP10ER/MEMEER EXCLUDED? It yes, describe under SPECIAL PROVISIONS below • 1 ro YSUM S �. J ER LL EACH ACCIDENT• ' $ ,E L DISEASE - EA.EMPt.OYEE _ $ E.L. DISEASE - POLICYLIMIT $ A Cr/HER 1 r Liability •{ ► 1/31/2003 10/31/2004 See Below LiSgRIPT10N O OPERATIONS 1 LOCATIONS 1 VEHICLES / EXCLU NS AD BY ENDO I $PE *AL PR IONS mits: $10,000 PD each occurrence /$300,000 BI each person and each occurrence/$300,000 loss of support each person and each occurrence /$600,000 aggregate limit per club. • kigoi City of Lino Lakes Lino Lakes, MN WOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, t7$ MEWS ORREPREEENTATNES. ACORD 25 (2001108) AUTHORIZED REPRESENTATIVE Jane Johnson /MARYB -Ate- yefluf.44,1) CACORD CORPORATION 1988