2017.04.17 CC Packet - Laserfiche WebLink

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7DATE (MWDDNYYY) A� o® CERTIFICATE OF LIABILITY INSURANCE 1/22/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pol)cy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Customer Care Center NAME: West Bend Mutual Insurance Company PHONE (866) 926-4244 FAX (asa)ass-zzoo (p C N-Q,Extl: WC, Not: 1900 South 18th Avenue E-MAIL customercare@wbmi.com ADDRESS: West Bend WI 53095 INSURER(S) AFFORDING COVERAGE NAIC# INSURED Hugo Lions Club PO Box 321 INSURER A :West Bend Mutual Ina INSURER C : INSURER D : Hugo MN 55038 I INSURER F: COVERAGES CERTIFICATE NUMBER:17/18 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EFF POM/DD,YYYYi EXP ILTR TYPE OF INSURANCE NS13AbDW b POLICY NUMBER MM 0ICY LTR LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1, 000, 000 A CLAIMS -MADE X❑ OCCUR DAMA TO RENTED 100,000 PREMISES, Ea occurrence, � $ A108567 1/1/2017 1/1/2018 MEDEXP(Anyoneperson) $ PERSONAL & ADV INJURY $ 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO ❑ LOC JECT PRODUCTS - COMP/OPAGG . $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY _. BIN IN LE LIMIT [Ea accident) $ BODILY INJURY (Per person) ANY AUTO $ ALL OWNED SCHEDULED $ BODILY INJURY (Per accident) AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS @ Per accZ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE $ DED RETENTION <: WORKERS COMPENSATION R TH- AND EMPLOYERS' LIABILITY Y / N STATUTE - ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ A Liquor Liability A108575 1/1/2017 1/1/2018 Common Cause Limit 1,000,000 Aggregate 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is listed as additional insured for general liability per form WB1890. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Hugo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 14669 Fitzgerald Ave N ACCORDANCE WITH THE POLICY PROVISIONS. Hugo, MN 55038 AUTHORIZED REPRESENTATIVE Sam Gruber/TANYA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401)