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HomeMy WebLinkAboutAcord-9/7/2010 (2)CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/07/2009 PRODUCER (563) 547-2161 V & V Insurance Agency, Inc PO Box 159 103 6th St E Cresco IA 52136 - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED SNO HAWKS INC. 1314 WASHINGTON ST CEDAR FALLS IA 50613 - INSURER A: Dakota Fire Insurance Co INSURER B: INSURER C; INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTAN DING 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L ►NSRD TYPE OF INSURANCEDATE POUCY NUMBER POUCY EFFECTIVE IMM/DDJYYYY1 POLICY EXPIRATION DATE (MMIRQIYYYY)_ LIMITS DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN GENERAL UABIUTY COMMERCIAL GENERAL LIABILITY 3D31117 / / / / 12/01/2009 / / / / / / / / / / - / / 12/01/2010 / / / / / / / / EACH OCCURRENCE $ 1,000,000 $ X GE TO PREM SES Ea occuE ence) IMPOSE NO OBUGATION OR UABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR X CLAIMS MADE OCCUR MED EXP (Anyone person) $ REPRESENTATIVES. PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ 1,000,000 GENII AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY JJEECT LOC AUTOMOBILE UABIUTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE UABILITY ANY AUTO / / / / / / / / / / / / AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY / / / / / / / / / / / / / / / / / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ $ WORKERS AND EMPLOYERS' ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER (Mandatory If yes, describe SPECIAL COMPENSATION LIABILITY Y / N / / / / / / / / / / / / / / / / WC STATU- OTH- TORY I IMITS ER E.L. EACH ACCIDENT $ EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ In NH) under PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER / / / / / / / / / / / / DESCRIPT1ON OF OPERATIONS / LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Snowmobile Club and Trail Liability Insurance, including Liability coverage for (1) Groomer and (1) ATV (for trail maintenance). Additional insured for 'other then' trail usage - Five Star Snow Trails Assn % Dave Barber 345 Lobeck Ave REadlyn, IA 50668 and Additional insured for trail usage - See (4) attached sheets. Premise liability coverage is Excluded on this policy. This policy has a $250.00 deductible per claim. CERTIFICATE HOLDER CANCELLATION ( ) — ( ) — SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR UABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE/ -4--- / �� ACORD 25 (2009/01) INS025 (200901) ©1988-200OI(f AIT r,i hts reserved. The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009/01) INS025 (200901) CLUB NAMEz SNO HAWKS, INC. LANDOWNERS AS ADDITIONAL INSURED FOR CLUB CONTRACTED TRAIL USAGE ONLY 61. Mary D Shining Trust 5311 Hyacinth Drive Unit 64 Cedar Falls, IA 50613-6415 71. Charles Wilmot 2596 Joplin Avenue Denver, IA 50622 62. William A. Shining Trust 5311 Hyacinth Drive Unit 64 Cedar Falls, IA 50613-6415 72. Raymond & Pauline Youngblut 6732 LaPorte Road Waterloo, IA 50706 63. p.onald Steege • 9321 Logan Avenue Waterloo, IA 50703 73. Tim Youngblut 6905 LaPorte Road Washburn, IA 50706 64. ugene E. & Jean M. Stokes 8225 Ford Road Cedar Falls, IA 50613 74. David M. & Nancy J. Zeien 4622 West Cedar Wapsi Road Cedar Falls, IA 50613 65. Tall Fine Farms, Inc. ' 7411 North Raymond Road llunkerton, IA 50626 75. The State of Iowa & All of its political Subdivisions Wallace State Office Building Des Moines. IA 50319 66. Michael & Kathy Tellinghuisen 7611 North Union Road Janesville, IA 50647 76. Five Star Snow Trails Association 5912 Aster Lane Waterloo, IA 50701 67. Clifford R. & L. Marcella Trent $339 Leversee Road Cedar Falls, IA 50613 77. City of Janesville Iowa 227 Main Street Janesville, IA 50647 68. Alan & Marilyn Walker 13.03 East Bennington Road Waterloo, IA 50703 69. Washburn BP Store 7305 LaPorte Road Washburn, IA 50702 70. Waterloo Industrial Development ,10:West 4th Street . Waterloo, IA 50701 • Page 4 of 4 MASTER POLICY NAME: IOWA STATE SNOWMOBILE POLICY # 3D31117--10 ASSOCIATION * SNOWMOBILE CLUB CERTIFICATE * CARRIER: DAKOTA FIRE INSURANCE COMPANY EFFECTIVE DATE: 12-01-09 TO: 12-01-10 RETROACTIVE DATE: 11-30-04 CLUB #: 052 CLUB NAME: SNO HAWKS INC ENDORSEMENT#: 01 ADDRESS: 1314 WASHINGTON STREET CEDAR FALLS, IA 50613 COVERAGE : SNOWMOBILE CLUB ONLY ® SNOWMOBILE/ATV CLUB ❑ TRAIL LIABILITY EXPOSURE: YES ❑ NO CLUB PREM ENDST FILING FEE NO SURPLUS LINES TAX STAMPING FEE TAX SL SERVICE CHARGE PREMISES LIABILITY EXPOSURE 0 YES PREMISES LOCATED AT: #GROOMERS: 1 #/USE OTHER EQUIPMENT: 1 - ATV USED FOR TRAIL MAINTENANCE ONLY #EMERGENCY SLEDS: 0 (EMERGENCY SLED) ISA SPECIFIC SLED ATTACHED TO A SNOWMOBILE TO CARRY INJURED PEOPLE TO AN EMERGENCY VEHICLE WHEN DUE TO WEATHER THE EMERGENCY VEHICLE CANNOT GET TO THE INJURED PARTY. ***WARRANTED THAT AN EMT OR PARAMEDIC MUST ACCOMPANY OUR SNOWMOBILE CLUB DRIVER. (NO PROFESSIONAL LIABILITY COVERAGE IS PROVIDED) $1065.00 MP +❑APPLIES +ZAPPLIES +DAPPLIES +❑APPLIES COVERED CLUB ACTIVITES: SEE ATTACHED SCHEDULE OF SPECIFICALLY COVERED ACTIVITIES ****************************************************************************** THIS CLUB IS MADE UP OF OTHER INDIVIDUAL CLUBS WHO EACH CARRY THEIR OWN CLUB LIABILITY POLICY FOR THEIR ACTIVITIES. 0 YES NO IF YES, THE FOLLOWING EXCLUSION APPLIES TO THE COVERAGE PROVIDED FOR THE CLUB LISTED ABOVE. EXCLUSION: IT IS HEREBY AGREED AND UNDERSTOOD THAT "NO COVERAGE" EXISTS FOR ANY ACTIVITIES OF THE INDIVIDUAL CLUBS WHICH MAKE UP THE CLUB: ****************,**************,************************************************ ADDITIONAL INSURED' S ONO AYES SEE ATTACHED ENDORSEMENT **OTHER THAN CLUB CG7501 (1-06) CONTRACTED LANDOWNERS FOR USE OF TRAILS ONLY LIMITS: $1,000,000 OCCURRENCE $1,000,000 GENERAL AGGREGATE **COVERAGE IS FOR SPECTATOR LIABILITY ONLY. COVERAGE FORMS APPLICABLE ARE THE SAME AS SCHEDULED ON THE MASTER ASSOCIATION POLICY. IF YOU HAVE ANY QUESTIONS YOU SHOULD REFER TO THE ASSOCIATION FOR POLICY INFORMATION. DATE ISSUED: 12/18/09 HB -eU INSURANCE AGENCY P.O. PnoGne (563) 547•2!,31 °a. No. (563) 547-2046 insorance@vandvms.com DALE VAGTS COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION - VICARIOUS LIABILITY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE* Name of Person or Organization: SEE ATTACHED * If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement. A. SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person or organization shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. B. This insurance does not apply to any "bodily injury", "property damage" or "personal and advertising injury" resulting from any act or omission by, or willful misconduct of the additional insured shown in the Schedule, whether the sole or a contributing cause of the loss. The coverage afforded to the additional insured is limited solely to the additional insured's "vicarious liability" that is a specific and direct result of your conduct. "Vicarious liability" as used in this endorsement means liability that is imposed on the additional insured solely by virtue of its relationship with you, and not due to any act or omission of the additional insured. Includes copyrighted material of ISO Properties, Inc. with its permission. CG7501 (1-06) Page 1 of 1