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7DATE (MWDDNYYY) <br />A� o® CERTIFICATE OF LIABILITY INSURANCE <br />1/22/2016 <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 pol)cy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER CONTACT Customer Care Center <br />NAME: <br />West Bend Mutual Insurance Company PHONE (866) 926-4244 FAX (asa)ass-zzoo <br />(p C N-Q,Extl: WC, Not: <br />1900 South 18th Avenue E-MAIL customercare@wbmi.com <br />ADDRESS: <br />West Bend WI 53095 INSURER(S) AFFORDING COVERAGE NAIC# <br />INSURED <br />Hugo Lions Club <br />PO Box 321 <br />INSURER A :West Bend Mutual Ina <br />INSURER C : <br />INSURER D : <br />Hugo MN 55038 I INSURER F: <br />COVERAGES CERTIFICATE NUMBER:17/18 REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, 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 HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />EFF POM/DD,YYYYi EXP <br />ILTR <br />TYPE OF INSURANCE NS13AbDW b POLICY NUMBER MM 0ICY <br />LTR LIMITS <br />X COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE $ 1, 000, 000 <br />A <br />CLAIMS -MADE X❑ OCCUR <br />DAMA TO RENTED 100,000 <br />PREMISES, Ea occurrence, � $ <br />A108567 1/1/2017 1/1/2018 <br />MEDEXP(Anyoneperson) $ <br />PERSONAL & ADV INJURY $ 11000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE $ 2,000,000 <br />X POLICY PRO ❑ LOC <br />JECT <br />PRODUCTS - COMP/OPAGG . $ 2,000,000 <br />OTHER: <br />$ <br />AUTOMOBILE LIABILITY <br />_. <br />BIN IN LE LIMIT <br />[Ea accident) <br />$ <br />BODILY INJURY (Per person) <br />ANY AUTO <br />$ <br />ALL OWNED SCHEDULED <br />$ <br />BODILY INJURY (Per accident) <br />AUTOS AUTOS <br />NON -OWNED <br />PROPERTY DAMAGE <br />$ <br />HIRED AUTOS AUTOS @ <br />Per accZ <br />$ <br />UMBRELLA LIAB OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LIAB CLAIMS -MADE <br />$ <br />DED RETENTION <: <br />WORKERS COMPENSATION <br />R TH- <br />AND EMPLOYERS' LIABILITY Y / N <br />STATUTE - ER <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />E.L. EACH ACCIDENT $ <br />OFFICER/MEMBER EXCLUDED? N / A <br />(Mandatory in NH) <br />E.L. DISEASE - EA EMPLOYE $ <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE - POLICY LIMIT 1 $ <br />A Liquor Liability <br />A108575 1/1/2017 1/1/2018 Common Cause Limit 1,000,000 <br />Aggregate 1,000,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />Certificate holder is listed as additional insured for general liability per form WB1890. <br />CERTIFICATE HOLDER CANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />City of Hugo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />14669 Fitzgerald Ave N ACCORDANCE WITH THE POLICY PROVISIONS. <br />Hugo, MN 55038 <br />AUTHORIZED REPRESENTATIVE <br />Sam Gruber/TANYA <br />01988-2014 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD <br />INS025 (201401) <br />