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A60RH CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DD/YYYY) `./1 11/22/2016 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 policy(les) 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 r Exts: (866) 926-4244 FAX (262)365-2200 1900 South 18th Avenue E-MAIL customercare@wbmi.com ADDRESS: West Bend WI 53095 INSURER(S)AFFORDING COVERAGE NAIC # PRODUCTS GCOMP/OP 2,000,000 INSURERA:West Bend Mutual Insurance _Company 15350 INSURED INSURER B Hugo Lions Club INSURERC: PO BOX 321 INSURER D: BODILY INJURY (Per person) $ INSURER E: Hugo MN 55038 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. INSR - — - IADDLISUBR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP --- --..._. MM'DDn';'YY' MM/DD/rvvr LIMITS X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ 1, 000, 000 DAMAGETOAENiED _ A CLAIMS -MADE X1 OGCUR PREMISES I Ea occurrence) $ 100,000 A108567 1/1/2017 1/1/2018 MED EXP (Any one person) $ _PERSONAL & ADV INJURY $ 1,000,000 APPLIES PER: NPOLLIICYE❑ GENERAL GREGATE $ 2,000,000 PAGG$ X j CT ❑OC PRODUCTS GCOMP/OP 2,000,000 OTHER: $ AUTOMOBILE LIABILITY IMBINED SINGLE LIMIT $ _LEa accident _ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS _Per accident__ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB _ CLAIMS-MADEi AGGREGATE $ DED RETENTION. $ WORKERS COMPENSATION PER OTH. AND EMPLOYERS' LIABILITY Y / N ' __ STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA — - (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ It yes, describe under -- DESCRIPTION OF OPERATIONS_ below E.L. DISEASE - POLICY LIMIT $ I 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 H more space Is required) Certificate holder is listed as additional insured for general liability per form WB1890. City of Hugo 14669 Fitzgerald Ave N Hugo, MN 55038 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Sam Gruber/TANYA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401)