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A4i?V CERTIFICATE OF LIABILITY INSURANCE s3ATEtr.IhYDDIYYiY <br />lli-� 1 05102/2024 <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 endorsements). <br />PRODUCER CONTACT Will Maddllx <br />NAME: _ <br />=ast Main Street Insurance Services. Inc P"°IC,NE - (530) 477-6521 I FAX Na,: _ <br />Will Maddox E-MAIL <br />info fftheeventhelper clam <br />P❑ Box 1298 IHSURER(SIAFFORQ]NGCD_VERAGE =1 NAIC <br />Grass Valley CA 95945 INSURER A: EVaris6 Insurance Company 3537EI <br />INSURED wsu RER 9 <br />IINSURER C <br />Arving Smith INSURER Q: <br />301 76th Ave Al INSURER E : <br />BrooOynParr NIN 55444 INSURER <br />COVFRAGFS CERTIFICATE NIJMRFR- REVISION MLIMRFR- <br />T mIS IS TO CEFtTIF1'' THAT TnE POLICrES OF INSURANCE LrSTED BELOW HAVE BEEN ISSLIED TO THE INSURED NAMED ABOVE FOR THE POLiM PERIOD <br />INDICATED NOTWITHSTANDING ANY REGUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER. DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFCRDE❑ 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 />IEXP <br />TYPE OF INSURANCE i[�DLI POLICY NUMBER MYIYYYYr PW MMV YYYY17 LIMJTS <br />LTR M/QQ <br />LTFI <br />COMMERCIAL GENERAL LIABILITY <br />EACFIOCCURRENCE <br />S 1-000.000 <br />CLAIMS -MADE X OCCUR <br />LPIMA_ <br />y *E"cFS (Pa o��ncei <br />: 100.000 <br />_+ <br />Host Liquor Liability <br />MED E` _ . -:;::_2 mixi) <br />A <br />_ <br />Retail Liquor Liability <br />Y <br />N <br />3DS5475-M3047175 <br />08/0212024 08104J2024 <br />ff�?NAL & ADV INJURY <br />_ _5.000 <br />1,000.000 <br />G'jE'N'L <br />AGGREGATE LIMIT APPLIES PER <br />12-01 AM 12:01 AM <br />GENERAL AGGREGATE <br />3 2.000.000 <br />POLICY [] PRO 3ECT L OC <br />_ <br />PRODUCTS - COMPQP AGG <br />— -- <br />i 2.000.000 <br />IY'HrzR: <br />I <br />Deductible <br />= 1 400 <br />AUTOMOBILELIIABILITY <br />COMBINED SINGLE LIMIT <br />{Ea accident__ <br />a <br />a <br />ANY AUTO <br />HODJLY INJURY (Perpersmn <br />OWNED SC:HEDU�_ED <br />AUTOS ONL4 ALTOS <br />HODJLY INJURY (Per acciaell. <br />E <br />HIRED NON-04NED <br />.;,ROP RT�I EIAIVINSE <br />a <br />AUTOS ONLY AUTOS ONLY <br />S <br />UMBRELLA L]All OCCUR <br />CFI 0CICU R€iENCE <br />a' <br />a <br />EXCESS UAR CLAIMS-irrAOE <br />AGGREGATE <br />a' <br />DEG RETENTIONS <br />WORKERS COMPENSATION <br />PER O� <br />AND EMPLOYERS' LIABILITY <br />3TA—TI TE EST <br />4i'r?RrPRIETDRIPARTNER�EJCECUTiVE � <br />r L EACH ACCIDENT <br />a <br />❑=RCERlMEihBERD(CLUDED? <br />NIA <br />ILL DISEASE-EAEMPLOYEE <br />; <br />{JMandatoryia NRI <br />If ys, describe under <br />OF OPERATIONS bebw <br />i=L DISE43E . POLICY LIMIT <br />i <br />11DESCRIPTION <br />1 <br />1 <br />DESCRIPTION OF OPERATION51 LOCATIONS 1 VEHICLES SACDRD 101, Additional Remarks Schedule, may he attached if more space is required) <br />Certificate holdef listed below is named as addibonaI insured per attached MEGL 2217 01 19 Attendance. 340, Event Type. Anniversary Party- Open to the <br />PubliclNo Admission Charge. <br />r r-PTIFIr`_ATE wni r1FR r'ANr 1=I I ATInNI <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 />Mounds View COMmunity Center <br />5394 Edgewood Dr <br />AIITHORJIED REPRESENTATIVE <br />!�� <br />Mounds View AN 55i1 2 <br />J <br />e: 1989-2015 ACORD CORPORATION. All rights reserved. <br />ACORD25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />