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AC40)?a CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) <br /> 1/31/2013 <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 policy(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 <br /> NAME: Judy Weaver <br /> STAR Insurance - Fort Wayne Office PHONE (260)467-5697 FAX <br /> A/C No:(260)467-5651 <br /> 2130 East Dupont Road E-MAIL <br /> ADDRESS: j .ud weaver@starfinancial.com <br /> INSURERS AFFORDING COVERAGE NAIC# <br /> Fort Wayne IN 46825 INSURERA: National Casualty CompanV 11991 <br /> INSURED INSURER B: Nationwide Life Insurance Co. 66869 <br /> Road Runners Club of America 2013 & Its INSURERC: <br /> Member clubs INSURER D: <br /> 1501 Lee Highway, Suite 140 INSURER E: <br /> Arlington VA 22209 INSURER F <br /> COVERAGES CERTIFICATE NUMBER:2013 - $11A A.I. 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 /> INSR ADDL SUBR POLICY EFF POLICY EXP <br /> LTR TYPE OF INSURANCE WVD POLICY NUMBER MM/DD/YYYY MMIDD/YYYY LIMITS <br /> GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 <br /> X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED <br /> PREMISES Ea occurrence $ 500,000 <br /> A CLAIMS-MADE I—XI OCCUR X KRO 000000 3086500 12/31/2012 12/31/2013 MED EXP(Any one person) $ 5,000 <br /> X Legal Liability to 12:01 A.M. 12:01 A.M. PERSONAL&ADV INJURY $ 1,000,000 <br /> Participant $1,000,000 GENERAL AGGREGATE $ NONE <br /> GEN'L AGGREGATE LIMIT APPLIES PER: use & Molestation PRODUCTS-COMP/OP AGG $ 1,000,000 <br /> X POLICY PRO LOC r9gregate $5,000,000 ABUSE& MOLESTATION $ 500,000 <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT <br /> Ea accident $ 1,000,000 <br /> A ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED O 000000 3086500 12/31/201212/31/2013 <br /> AUTOS AUTOS X BODILY INJURY(Per accident) $ <br /> X X NON-OWNED 12:01 A.M. 12:01 A.M. PROPERTY DAMAGE $ <br /> HIRED AUTOS AUTOS Per accident <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED I I RETENTION$ $ <br /> WORKERS COMPENSATION WC STATU- I OTH- <br /> AND EMPLOYERS'LIABILITY Y/N <br /> TORY LIMITS ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE <br /> OFFICER/MEMBER EXCLUDED? H N/A E.L.EACH ACCIDENT $ <br /> Mandatory in <br /> (f yes,describe under E.L.DISEASE-EA EMPLOYE $ <br /> I <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> B EXCESS MEDICAL & ACCIDENT X SPX 00000 25699000 12/31/2012 12/31/2013 EXCESS MEDICAL $10,000 <br /> ($250 DEDUCTIBLE/CLAIM) 12:01 A.M. 12:01 A.M. AD&SPECIFIC LOSS $2,500 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) <br /> CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS RESPECTS THEIR INTEREST IN THE OPERATIONS OF THE <br /> NAMED INSURED. <br /> DATE OF EVENT: 03/16/13 Lodi Mile INSURED CLUB/EVENT MEMBER: TSH Inc, attn: Monty Merrill, 631 South <br /> Ham Ln, Lodi CA 95242 <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> 03/16/13 The County of San Joaquin ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 1810 E Hazelton Ave <br /> Stockton, CA 95205 AUTHORIZED REPRESENTATIVE <br /> John Lefever/LORENZ <br /> ACORD 25(2010/05) <br /> ©1988-2010 ACORD CORPORATION. All rights reserved. <br /> INR025 r^n,.nn.,�n1 rleca A(°fiF2rl n�€mac��zrl Innen a¢°v:_rcic,crc�sl mni-kc ne Ornpn <br />