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w DATE (MMIDD/YYYY) <br />`�Cp�� CERTIFICATE OF LIABILITY INSURANCE o(,(I`;l(,)I <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(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER NAME: YOI-ANDAGAR111AY <br />IMPACYINSURANCIFAW'.NCY INC 4TOwa €aI 61"' V)4-2700 NGW]-X24-i1J1 <br />"AI29294-I'llAV1[6ST1i 105 ADDRESS: impac.linugcncy(ri., r,ail,rnm <br />INSURER(S) AFFORDING COVERAGE NAIC H <br />MINNISAPOLIS VIN 55408 wsURERA: RAVIFLFASINSI:RAN(.1'. <br />INSURED <br />INSURER B <br />SA\'ILO 1, C INSURER C: <br />2:}45 COUNTY ROAD I1-1 INSURER D, <br />INSURER E <br />MOHNDS VIli1V MN S5112 47o", I INSURER F: <br />COVERAGES r:FRTIFICATF MIIMRICR• RFVICInm NI IMRFR- <br />THIS IS TO CERTIFY THAT 1 HE POLICIES OF INSURANCE LIS I ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 1 HE POLICY PERIOD <br />INDICATED, NOTWITHSTANDING ANYREQUIREMENT, 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 HFREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SI )OWN MAY I IAVE BEEN REDUCED BY PAID CLAIMS. <br />LTR <br />TYPE OF INSURANCE <br />pNSD <br />WVRD <br />POLICY NUMBER <br />(MtNID4lYYYYI <br />j"!WD Y Y" <br />- — <br />MMID I <br />(MMIDD/YYYY) <br />LIMITS <br />COMMERCIAL GENERAL LIABILITY <br />EACH o'.x;uHRENL:E <br />� I,III;it,r�Clll <br />CLAIMS MADE 00CC'!R <br />PREMISES IErr nrnw rrnm) <br />':5-111U,0(1l) <br />q�ED EXP 01., cute puts";,) <br />$ 50,000 <br />PERSONAL &ADVINJURY <br />$ 5X45(KI <br />Y <br />Y <br />9R4WXR ABIP <br />5:<(;12 <br />U2r15_'0.+ <br />GEN'L AGGREGATE LIN11T APPLIES PER: <br />CENFRAL AGGREGATE <br />2,U(IU,UIIU <br />POLICY5 <br />�JEC'I nLOC <br />PRODIJC:IS-GOMPlOPAGG <br />b=,000,U(lO <br />OTHER : <br />AUTOMOBILE LIABILITY <br />'u <br />g <br />BOW Y INJURY (1'et person) <br />S <br />- <br />ANY AU1 O <br />OWNED SC'' IFDULFD <br />i14,IC,M ONLY AU1-OS <br />BODILY INJURY IPer accident) <br />G <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />{Pnr :xdllltlnl <br />S <br />UMBRELLA LIAB OCCUR <br />, i! - '� I UCCIJRRCNCE <br />EXCESS LIAB CI AIMS-NIADE <br />T <br />b <br />AGLGP.I-GAI_ <br />DED RETENTION $ <br />WORKERS COMPENSATION <br />- �- <br />AND EMPLOYERS' LIABILITY Y I N <br />ANY PROr'RIETOR/PARTNERIEKECl1TIV5 <br />CICA;'RIMEMBER EXCLUDED? I <br />f �.J <br />I <br />NIA <br />S, <br />lAliiIL 6P <br />- <br />I.L _RPP ACCIL'ENf <br />5 <br />E L DISEASE - EA EMPLOYEE <br />$ <br />Mm,dAkKVw NHI <br />f ycs, describe undar <br />DESCRIP fION OF OPERAI IONS beluvr <br />EL OISEASE - POLIO' LJVI-1 <br />S <br />.. �."nir,nn. .,r air �nni.,rvo i u�i.A nUrva, vOnll.LtS (AUUnU -I I, AnnIUOON KCrne(--nomUP, may oC attncnen If more SPTGe IG rP.f l-,i) <br />LIQUOR L[Ali ILITY INC'LUDLD IN POLIC'1' LIQUOR LIABILITY lAC'LLDGD IN I'OL IC'Y <br />TE HOLDER <br />CITY 01 MOUNDS VIFAV <br />CANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />')401 MOUNDS Vll.AV HOUI G\'ART) AUTHORIZED REPRESENTATIVE <br />MOUNDS VII:AV <br />ACORD 25 (2016103) <br />Y01 ANDA (1ARMAY <br />YIN 55112 <br />C�J 1988-2015 ACORD CORPORATION All rights reserved <br />The ACORD name and logo are registered marks of ACORD <br />