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HomeMy WebLinkAboutCertificate of Insurance�;;o g "ACORUCERTIFICATE OF LIABILITY INSURANCECC o� 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(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 NAME LT John Adams DSP Insurance JA °_'� FSI: 1-80D-316-6705 I INCFAXNo): 847-934-6186 1900 E. Golf Road, Suite 650 EMAIL IionsciubsQdspins.com ADDRESS: Schaumburg, IL 60173 INSURER(S)AFFORDING COVERAGE NAICA INSURER A: ACE American Insurance Company 22667 INSURED IIISURER B. I INSURER C : Sebastian Lions Club Sebastian Florida (INSURER D: 114SURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: "HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOLV HAVE BEEN ISSUED TO THE INSURED NALIED ABOVE FOR THE POLICY PERIOD INDICATED NOT NITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO `.:'HIGH THIS CERTIFICATE 41AY 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 CLAIh1S (NSR AUDI. SUBR LTR TYPE OF INSURANCE INV.R IytII, POLICY NUMBER POLICY EFF POLICY EXP I tMMiDDNYYY) IMMIDDIYYYn LIMITS A GENERAL LIABILITY EACH OCCURRENCE S 1.000.000 X CCt.'.1ERCIAL GENERAL LIABILITY HDOG71094972 09/0112018 09/01/2019 pRE1. "Aur IEa occurrence! S 1.000,000 CLAIMS -MADE Q OCCUR I ACED JCP (A%, cne person) S 5.000 X Aug. Per Named Insured PERSONALS ADV INJURY S 1.000.000 is $2,000.000 I GENERAL AGGREGATE S 10,000,000 _ GN L AGGREGATE ELIIAT APPLIES PER I PRODUCTS - CON.IP:'CP AGG S 2.000.000 y l POLICYn ;Frr n LO r S A AUTOMOBILE LIABILITY (EOAa'derd) LE user S 1.000,000 ISAH25159226 09/01/2018 09/01/201 v BODILY INJURY (Per person) S ANY AUTO SCHEDULED I BODILY ISI iURY (Per xcdent) S AUTOS X HIREDAUTOS AUTOS AUT AUTOS PROPERTY P.tAGE S 5 UMBRELLA LIAR H0CLcAcuR EACH OCCURRENCE S EXCESS LIAR I,IS,.1A,E AGGREGATE S DED I RETENTIOVS S WO IKERS COMPENSATION I ' :C STATU• I IOTH• I irav r n.CrT A �R AND EMPLOYERS' LIABILITY ! ANY PRCPR ETORVART�NERfXECUTIVE 7 I ! I EL EACH ACCIDENT S OF CERMEWSER EXCLt DE07 N A I I (Mandatary to NH) E.L. DISEASE . EA EMPLOYEE. S I^ %e.. de;Crbe Cnder E�CRIPTION:,F OPERATIONSbMv I I E L DISEASE . POLICY LIMIT I S DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101. Additional Remarks Schedule. it more apace Is tequirod) Provisions of the policy apply to the named Insured's participation in the following activity during the policy period shown above: Sebastian Freedom Festival July 4th, 2019 PROVISIONS OF THE POLICY DO NOTAPPLY TO THE SALE OR SERVING OF ALCOHOLIC BEVERAGES. CERTIFICATE HOLDER CANCELLATION City SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Sebastian Main Street THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Sebastian Florida 32958 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTAT NE I (c) 1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE 0ATE 04/2JMUFD 412015 Ym THIS CERTIFICrATE 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 INSURCR(S), AUTHORIZCD 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 Willis of Illinois, Inc. 425 N. Martingale Road, Suite 1100 CONTACT NAME: John Adams PHONE 1-800-316.6705 1 LAA%G. No: 1-888467-2378 ADOREss: konsclubs@wilhs.com INSURE AFFORDING COVERAGE NAN:F Schaumburg, IL 60173 INSURER A: ACE American Insurance Company 22667 INSURED INSURER 8: INSURER C: 3512 Sabastinn Uona Club SEBASTIAN Florida WSURER D: INSU0.E0. E INSURER : HDOG27336395 CvvERACES CERTIFICATE NUMBER: 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 I TN TYPE OF INSURANCE POLICY NUMBER POLICY EFF YMNDIYY W EXpp n'TYY tlallT$ A GENERAL LIABILITY EACH OCCURRENCE S 1,000.000 X COMMERCIAL GENERAL LIABILITY ❑X OCCUR HDOG27336395 09/01/201409/01!2015 pM=ES TfEfiTrlenre 5 1,000,000 (EaaamisrnaoE MEo Exp (Arry one pasonj s 5,000 ACG. Per Named Insured PERSONAL &ADV INJURY S 1,000,000 is $2.000.000 GENERAL AGGREGATE s 10.000,000 GENL AGGREGATE X POLICY LVIT APPLIES PER PRO LOG PRODUCTS-COMPiOP AGO s 2.000,000 S A AUTOMOBILE LIABILITY ANY AUTO ISAH08827652 09/01/2014 GO=WNED SINGLE IRM Eaa¢IaeM s 1.000,000 09/01/2015ALL BWILY IMJLR3Y IPer person) 5 GINNED SCIIED AUTOS AUTOSULED BODILY INJURY Bree.a ) S HIREDAUTOS NON-OWNEDOT Pa xutlent S 5 UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS,MADE AGGREGATE S DED I I RETENTIONS S WORKERS COMPENSATION ANDEMPLOYERSLU181LITY YfNLIMIT ANY PROPRIETOR.TARTNERIEXECUTNE OrflCEiL'S$MBER EXCLUDED IManaAtory In NN) rt yyes. Aescrax OF O DESCRIPTION OF OPERATIONS Uegw NIA I WC STATU- 0TH EL EACH ACCIDENTS E L DISEASE. EA VAPLO S EI. DISEASE -POLICY LIMB s DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Anach ACORD 101. AtlNilional Remerks S I*dule. it more space is required) Provisions of thepolicy apPly to the named insured's participation in the following activity during the policy period shown above: SEBASTIAN fLORIDA tREEDOM FESTIVAL JULY 4TH. 2015 PROVISIONS OF THE POLICY DO NOT APPLY TO THE SALE OR SERVING OF ALCOHOLIC BEVERAGES. Cdy22of Sebastian Florida 15 Main Street Sebastian Florida 32976 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 ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD SUBST -5 OP ID: JS CERTIFICATE OF LIABILITY INSURANCE COVERAGES CERTIFICATE NUMBER: 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. DATE 31201YY) 06103/2013 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 Phone: 772-567-4930 NAME Ryan Weaver Insurance, Inc. Fax: 772-567-4931 CenterState Bank Bldg. 855 21 st Street - 2nd Floor Vero Beach, FL 32960 Ryan M. Weaver a,OO N Ext : - No E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC X INSURERA: Markel 38970 EACH OCCURRENCE $ 1,000,000 INSURED Substance Abuse Council of IRC INSURER B: Bridgefield Employers Ins Co 1507 20th Street Vero Beach, FL 32960 INSURERC: Philadelphia Insurance Co. GENERAL AGGREGATE $ 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRO LOC POLICYFI INSURER D: INSURER E A INSURER F: COVERAGES CERTIFICATE NUMBER: 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 LTR TYPE OF INSURANCE ALIUL NS bU13H POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMlDD,YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR X Sexual Molestatio Sebastian, FL 32958 8502SS3346802 01/25/2013 01/2512014 EACH OCCURRENCE $ 1,000,000 PREMISESEa occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 X Professional Liab GENERAL AGGREGATE $ 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRO LOC POLICYFI PRODUCTS- COMPIOP AGG $ 3,000,000 Emp Ben. $ 1,000,00 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS 8502SS3346802 01/25/2013 01/25/2014 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident A X UMBRELLALIAB X EXCESS LIAB OCCUR CLAIMS -MADE 602SS3346812 01/25/2013 01/2512014 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ DED I X I RETENTION $ 10000 $ B WORKERS COMPENSATIONWCSTATU- AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA BCIC0196-24851 01/10/2013 01/1012014 OTH- E.L. EACH ACCIDENT $ 1,000,000 1 000 000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 C D&O PHSD593424 01/25/2013 01/25/2014 Dir &Off 1,000,000 DESCRIPTION OF OPERATIONS, LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace is requlred) CERTIFICATE HOLDER CANCELLATION ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Lions Club of Sebastian 8025129th Court AUTHORIZED REPRESENTATIVE r Sebastian, FL 32958 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD SUBST -5 OP ID: JS ACORC?"F DATE (MMIDDfYYYY) CERTIFICATE OF LIABILITY INSURANCE 1 0610312013 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 pollcy(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). CONTACT PRODUCER Phone: 772-567-4930 NAME: Ryan Weaver Insurance, Inc.FaX: 772-567-4931 PoHfOONE Ext): AIC No FAX CenterState Bank Bldg. 855 21 st Street - 2nd Floor E-MAIL Vero Beach, FL 32960 ADDRESS: Ryan M. Weaver INSURER(S) AFFORDING COVERAGE NAIC INSURER A: Markel 138970 INSURED Substance Abuse Council of IRC INSURER B: Bridgefield Employers Ins Co 1507 20th Street INSURERC: Philadelphia Insurance Co. Vero Beach, FL 32960 INSURER D: INSURER E: INSURER F r`nvcD AR cc r GRTIP1rATlP NIIMRFR- RPvISInN NI IMRFR• 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. 1LTR TYPE OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDD/YYYY LIMBS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX_1 OCCUR X Sexual Molestatio AUTHORIZEDREPRESENTATNE Sebastian, FL 32958 8502SS3346802 01/25/2013 01125!2014 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 X Professional Liab I GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F—IJPERCof LOC PRODUCTS- COMP/OP AGG $ 3,000,000 JEmp Ben. $ 1,000,000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS 8502SS3346802 01/25/2013 01/25/2014 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 602SS3346812 01125/2013 01/2512014 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ DED I X I RETENTION $ 10000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICERIMEMBER EXCLUDED (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N 1 A BCIC0196-24851 01/10/2013 01/10/2014 WC STATU- OTH- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE- POLICY LIMIT $ 1,000,000 C D&O PHSD593424 01/25/2013 01/25/2014 Dir&Off 1,000,000 DESCRIPTION OF OPERATIONS f LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) I"COTI GI /"ATG U^1 rNMO rAWICI 1 ATInAI CITYOFS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Sebastian 1225 Main Street AUTHORIZEDREPRESENTATNE Sebastian, FL 32958 O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ACORO® CERTIFICATE OF LIABILITY INSURANCE OATE(MMfDDIYYYY) 06/09/2013 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 NAME John Adams PHO N 1-800-316$705 1 WC. No): 1-888467-2378 Willis of Illinois, Inc. E-MAIL lionsciubsvAllis.com ESS: 425 N. Martingale Road, Suite 1100 Schaumburg, IL 60173 INSURERIS) AFFORDING NwCa1 INSURER A; ACE American Insurance Company 22667 INSURED INSURER B: INSURER C: Sebastian Lions Club 35-N GENERAL AGGREGATE S 10,000,000 Sebastian Florida INSURER D: INSURER E: A —A INSURER r: COVERAGES CERTIFICATE NUMBER: 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. ILTR TYPE OF INSURANCE DL SUER POLICY NUMBER POLICY EFF M&ULDDY EXP LIMITS A GENERAL LIABILITY X COMMERCIALGENEIIALLIABRITY rvi CLAIMS4ADE04CCUR Aga. Per Named Insured X HDOG27012784 09/01/2012 0910112013 EACH OCCURRENCE S 1,000,000 PREMISES Eaoccwence S 1,000,000 MED EXP one n) S 1,000 PERSONAL & ADV INJURY S 1,000,000 is $2,000,000 GENERAL AGGREGATE S 10,000,000 GENL AGGREGATE LIMIT APPLIES PER X POLICY PECTRO LOC PRODUCTS - COMPIOP AGG S 2,000,000 S A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS AUTO ED ISAH08711392 09/01/2012 09/01/2013 eD SINGLE LIMIT S 1,000,000 (Ea BODILY INJURY (Per person) $ BODILY INJURY (Per accident) S (P a�� t GE g S UMBRELLA LIAROCCUR EXCESS LIAR HCLAIMS-MADE EACH OCCURRENCE S AGGREGATE S DEO I I RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETORIPARTNERIEXECUTIVE OFFlCERIMEMBER EXCLUDEW (Mauodatory in NN) llr desrnueunder DESCRIPTION OF OPERATIONS below N I A WC STATU- OTH- E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLO 5 E.L. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Provisions of the policy apply to the named insured's participation in the following activity during the policy period shown above: Sebastian Florida\'s Freedom Festival July 03-04, 2013 PROVISIONS OF THE POLICY DO NOT APPLY TO THE SALE OR SERVING OF ALCOHOLIC BEVERAGES. CFRTIFICATF 11ALDFR CANCELLATION ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Citu of Sebastian, Florida y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1225 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Sebastian Florida 32958 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ACOMCERTIFICATE OF LIABILITY INSURANCEDATE 04/29/04 PRODUCER (630)324-2500 FAX (630)324-2501 T.J. Adams Group, LLC 333 E. Butterfield Rd., Suite 500 Lombard, IL 60148 OI -YPNDCONFEFtSNOF IrHMLJPONTFECERTPICATE HOIDERTHIS CERTIFICATE DOES NOTA AENDEXIENDOR NS1A3675AFFOFmN1GCOVERAGE NSURM Sebastian Lions Club Florida INSURERA ACEAmenprT Insurance INSURERS: INSURER C: INSLIRMD INSURERS OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE 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 NSURMICEAFFORDED BYTHE POLICES DESCRIBED HEREIN B SUBJECTTOALL THE TERMS. EXCLUSIONSAND CONDMCNS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPECFNRIRNJCE PCLICYNUNEER POUCV LIMITS A GENERAL LIABILITY x MNTSRCKLGB48VLLKXJTY CLNMSM4DE a OCCUR GENL AGGREGATE UMITAPPLIES PER: 17 POLICY f7PROJECTF7O ' HDO31731935 0901/2003 0901Y2004 EACH OCCURRENCE $ , 000000 FIREDAMAGEWWmIlm) $ 1,000,000 MEDEXP("y ,,aw $ , ,000 PERSONN.&ADVINIURY s 1.000.000 GENERPLAGGREGATE $ 2,000, 000 PRODUCTS -COMPIOP AGG $ 2000000 A AUTOMOBILE X X LMaILITY ANY AUTO ALL OWNEDAJTO.S SCHEDULEDAUTOS HIRED AUTOS NON -O MEDAUTOS i DOG17319W 09012003 09012014 CANBN3TSPX4.ELMT 5 (n('l, (JdBd In Above PW S) BODILY INJURY ref p ) s BODILY NRIRV S (Peracciae~) PROPERTY DAMAGE $ (Per 8=48 ) GA LADELIABILITY ANYAUTO NOTCGJERED AUTO ONLY -EA ACCIDENT S OTHER THAN EAACC S AUTO ONLY, AGG S EXCESS LIABILITY OCCUR ❑ CLAIMS MADE DEDUCTIBLE RETEINTION $ - NOT COVERED EACH OCCURRENCE $ AGGREGATE S $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY NOTCOVERED I W T OTHER E L. EACH ACCIDENT S ELD8EASE-EAEMR.0r EE 5 E L. DISEASE -POLICY LINT I $ DESCRIPTION OF OPERATIONS/LOCATIONSIVEIIICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS of policy apply to the Sebastian Lions Club for their conducting the 4th of July Celebration on July 3, 2004. of Sebastian, Florida is an additional insured(s), but only as respects liability arising out of use of premise by the Sebastian s Club and not out of the sole negligence of said additional insured. ADDITIONAL INSURED: INSURER LETTER City of Sebastian, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE Florida EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL - DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHQRIZED P ACORD 25S (7/97) // ACOROCORPORATION 1988 RX Date/Time 09/02/2010 11:15 7722289111 09/'P�2/2010 11:20 77222e9111 PAGE -Policy 'kiumber".62-i13'0`0.2'3.1 5• :COMMON POLICY DECLARATIONS' Renewal of: THE BP-RLINGTO-N INSURANCE COMPANY IFIG-Companis? 'Homeoftiiee: iurtington,North 'Carollne Adm lnlstfativo Office: 23;6 -t nt arnet i onai Ftaed,' Bur I not on, No 27215 Claim eOffive: 238 International Road. surlington,NC-272is Item 1. Named Insured and Malting Address co,use: Sebastian Lions £l.++k Charity Foundatlan BASS UNDERWRITERS, HELSOURNS 13244 US Hwy 1, 1290 HWY AIA, STE 102 S In -lb A.r. t i a n SATELLITE BEACH FL 3Z9a8 Ft. 32 9 -17 Coda: 62sipw/FM Surplus Lines Broker License No,: Itern 2. Policy -Period ixtj-2!01-kM,. ',',S4nd:ira-.Tirna at you.r mairig address shown above.. .Item 3.' In return' 'subject.- to 'gill the.*terms:.of tftI!V,'.p a licy; -We ".69 fee -with you 'to' -p tdv id,w the 1 h su ran d 6.- Its: dtatel, I tl.:this"00 lc-y..:,Thii 0 a lie y. cb nsists'dt.th 16 Ilowin g-'e'ov e rage•pii-rtsf'o.r wh ic h a. � 6� rl�o - p, i6rnl ul,�' is.!§h own; th ete istrib, coverage: premium' isi Ji.1; 1:06..'Wh6i Premlum . Commercial Cetis.ral: I L I Corn-morcial. aiy $ 400:00' Totat-p6licy "mWW-br-DeposIt'IVremj.um. O05,00 Other,Ohatgaft p'! -a -pp Ijas b 1q. POLICY •rZ-R Ta.tal..0thor'Ohaigat S '9 2 4 SURPLUS LTNtS :.TA)i .1 42.00 Total Amv,unt,Qual' 'S '2'4 st,:Rvx CK.'Olrr! i0 71:n 84 ONCE A.40 Premium is: O'Flsit ❑A'u d iter b I@ Policy Minimum Pr'ern4rri 350.00 In the event you icitrica):tPili p6lici;,we will jetalnl00% Item 4. Fornns' d -arse in brits.0 0 lid sible to -this ppllcy: See"Llsting ofForms and Endorsements" (IFG-1-01 50) Item- 5 Fo-rrri -of'.8vairi,est. 7 E] `.Pertneiship- E] Joint.Venttfra LIrnited.Liabirity-Comp-any 93'Other Otg&mizatio'n, Including a Corporation Business -De CELEBRATION AT'THE PARK VARI01?8' VENOIRS WILL DISPLAY .&ND SELL PR6D;!.r,,Ts*�, THESE OECL'ARAVGKS 'r0GV.MER:-.WT'*'.VkC -06Vi40.N­P0LI0Y 60' N 0 I'T I 'ON S 'AND :.CO R ' StI�EjNtg*,t0M#L#0.� YERAGE FORM(S) AND ANY HE M30VE'Nij SERED -PO ENDO M UdY.' SURPLUS -LINES JNSUReiR!,9,-?D.LICY'.*-RATES-AN-D'PORMS.'ARE--NOT' APPROVED--BY-XrV­' -FLbk.[bA"!R-td:U.L-ATO-R-Y--A(3",�NCY' This insurance ls'ls"d,* j)-trsus,n td!.thd'FIo­'r1'd a'Surp lug. Lines'. low, Pirso ns'insur.ed by surplus lirits-cstrlers-do.fy 0 Insurance Guaranty Act to the extent of any right of-recov'gry'fo-fth `e obligatlon• of an insolvent, un licensed Insurer. Countereigned.,., Data:' By: Authorized'Reprresentative IF0W-0101' 0204 INSURED Plage 1 of 1 Willy, 02 RX Date/Time 09/02/2010 11,15 7722289111 09/.82/2010 11:20 7722289111 Bass Underwriters, Inc. INSURANCE BINDER P.003 PAGE 03 'HE TERMS AND CONDITIONS OF THIS CONFIRMATION OF INSURANCE MAY NOT COMPLY WITH THE SPECIFICATIONS SUBMITTE' OR CONSIDERATION. PLEASE READ THIS CONFIRMATION CAREFULLY AND COMPARE IT WITH ANY QUOTE AND SU8MISSIOi IOCUMENTS AND REVIEW THE POLICY FORMS FOR THE ACTUAL COVERAGES PROVIDED. N ACCORDANCE WITH YOUR INSTRUCTIONS, AND IN RELIANCE UPON THE STATEMENTS MADE BY THE RETAIL BROKER IN TH NSURED'S APPLICATIONISU OMISSION, WE HAVE OBTAINED INSURANCE AT YOUR REQUEST AS FOLLOWS: DATE ISSUED; PRODUCER: INSURED: INSURER: POLICY NO.: COVERAGE: POLICY PERIOD: TERM: RENEWAL OF: June 11, 2010 Kim Ellis Insurance Services Inc 990 US Highway 1, Ste A Sebastian, FL 32958 Y�r Sebastian Lions Club Charity Foundation S R 180 D 13244 US Hwy 1, Sebastian, FL 32958 Burlington Insurance CO A AM Best Rating Non -Admitted 6288002375 Special Events 7/3/2010 TO 7/4/2010 1 Day 12:01 A.M. STANDARD TIME AT THE LOCATION ADDRESS OF THE NAMED INSURED. THIS INSURANCE BINDER WILL BE TERMINATED AND SUPERSEDED UPON DELIVERY OF THE FORMAL POLICY(IES) ISSUE13 TO REPLACE IT. LIMITS OF LIABILITY: $1,000,000 Per Occurrence Limit $2,000,000 General Aggregate Limit Excluded Products & Completed Operations Limit $1,000,000 Personal & Advertising Injury Limit $ 100,000 Fire Damage to Others Limit $ 5,000 Medical Expense Limit Liquor Liability $1,000,000 Each Occurrence $2,000,000 General Aggregate Rating Basis Festivals and Celebrations 42102 1 Day Vendors and Exhibitors 42102 1 Day Liquor Liability Special Events 2000 Attendees RATING BASIS: DEDUCTIBLE: PREMIUM: $805.00 RX Date/Time 06/29/2011 09:30 7722289111 P.002 06/29/2811 09:42 7722289111 PAGE 02 M-29-2011 WED D8 42 AO (19 EMS K90 FAX No7713882067 8 001 'Z gS4all bods Chit 6Inae2 Bass Underwriters, Inc. INSURANCE BINDER NNE TOIM9 AND CDNbRIDNa W Txl$ CONflNlATX)N OF RaNNANC! LMY MOT CCMPLY WRN TME aPECIFKATN,Na SxaMn ,c R Cp,RDERATNIN. PLlABE REAe TM49 CONFOIMATION dARlrULLY ANO tLMPM! R Nttx ANY WOTE ANO aUBMIEMO CUNENTE AMO AENEW YNE PODCTrOAMa FORTMa ACTUAL geY6U0E8 PROVreaC. uARRMS��wIllCAmbxrE,1lIa5M0N. M MAK COTNNE�O R31J N EATNYOUR REWEST AE NW.L V- E STAT"ANTS MAW ON WE NEfNL KRONER IXTX GATE ISSUIM: June 15, 2011 PROOLICER: Kim Elie ImMnce SeNM Inc 990 US Highway 1, Ste A Sebastian, FL 32959 INSURED PRIMARY Sebastian Lions Quo Charity Foundation PHYSICAL AD12RE99• Indian River Cr S OR 512 Sebastian, FL 32958 INSURER: Burangton Inauranee Go A AM Best Radng Na Admmed POLICY NO.: MOS002736 CGYBRA 6: Sp"W Rvants pOL1OY PERN7O; 7/402011 TO 7/52011 TERM; 1 Day ROMAL OF: 12;e1 AY.9TANOARO m,E, E1ERMINAttDAND WE L�jlew OflNE�RY a F TN,a?NMRML paauas"oab UUMN O Po YQW Q$YW ACPLkgEIT. LIMITS OP LINTY- $1,M0.000 Per Occurrenba Ural $2,000,000 General Agglegsts Urne Droluded products 6 Compmea 0mvitions umN $1,000,000 Personal & Advarte ng inquiry Llmlt $ 100,000 Fire Damage to atrwers Unit $ 5,000 Madlbal EYpenee LlrNt $1000,000 Liquor -Eich OCou—noO $2,000,000 Liquor- Annual Aggregate Rating Basis FeatNels 8 0eisbrE8ons 42102 2,000 8 tendees Set up /lmlla down 1 day Liquor Liabil ty 54282 2,000 Mttendees $ NIL Ofthe premium stated below Is for Add Inds and to fulty eemed RATnJQ RM& DEDUOTIOLE,