K-2 - Special Events Application - Girls on the Run 5K

CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER 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 have ADDITIONAL INSURED provisions or 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 Palmer & Cay, LLC 6525 Carnegie Boulevard Suite 430 Charlotte NC 28211 CONTACT NAME: Sharon Holland PHONE (A/C No. Ext): 704-951-5160 FAX (A/C No): E-MAIL ADDRESS: [email protected] INSURED Girls on the Run Eastern Iowa Po Box 197 North Liberty IA 52317 GIRLONT-37 INSURER A: Philadelphia Indemnity Insurance Company 18058 INSURER B: Philadelphia Insurance Companies 18058 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 335534862 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. <table> <tr> <th>INSR LTR</th> <th>TYPE OF INSURANCE</th> <th>ADDL/INSR WVD</th> <th>POLICY NUMBER</th> <th>POLICY EFF. (MM/DD/YYYY)</th> <th>POLICY EXP. (MM/DD/YYYY)</th> <th>LIMITS</th> </tr> <tr> <td>B</td> <td>X COMMERCIAL GENERAL LIABILITY<br>CLAIMS-MADE X OCCUR</td> <td></td> <td>PHPK2647396</td> <td>2/1/2025</td> <td>7/1/2026</td> <td>EACH OCCURRENCE $1,000,000<br>DAMAGE TO PREMISES (Es occurrence) $1,000,000<br>MED EXP (Any one person) $20,000<br>PERSONAL & ADV INJURY $1,000,000<br>GENERAL AGGREGATE $3,000,000<br>PRODUCTS - COMPIOP AGG $3,000,000</td> </tr> <tr> <td></td> <td>GENYL AGGREGATE LIMIT APPLIES PER:<br>X POLICY PROJEC LOC OTHER:</td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td>B</td> <td>AUTOMOBILE LIABILITY<br>ANY AUTO<br>OWNED AUTOS ONLY X SCHEDULED AUTOS<br>Hired Autos Only X NON-OWNED AUTOS ONLY</td> <td></td> <td>PHPK2647396</td> <td>2/1/2025</td> <td>7/1/2026</td> <td>COMBINED SINGLE LIMIT (Es accident) $1,000,000<br>BODILY INJURY (Per person) $<br>BODILY INJURY (Per accident) $<br>PROPERTY DAMAGE (Per occurrence) $</td> </tr> <tr> <td>A</td> <td>X UMBRELLA LIAB X OCCUR<br>EXCESS LIAB CLAIMS-MADE</td> <td></td> <td>PHUB897838</td> <td>2/1/2025</td> <td>7/1/2026</td> <td>EACH OCCURRENCE $10,000,000<br>AGGREGATE $</td> </tr> <tr> <td></td> <td>WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY<br>ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Y/N</td> <td>N/A</td> <td></td> <td></td> <td></td> <td>PER STATUTE<br>E.L. EACH ACCIDENT $<br>E.L. DISEASE - EA EMPLOYEE $<br>E.L. DISEASE - POLICY LIMIT $</td> </tr> <tr> <td></td> <td>DED RETENTION S</td> <td></td> <td></td> <td></td> <td></td> <td>OTHER</td> </tr> </table> DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER City of Tiffin 300 Railroad Street PO Box 259 Tiffin IA 52340 USA CANCELLATION 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 Sharon Holland