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DocuSign Envelope ID: 5539D016-1 E57-46E8-9BDE-A200E91 F5A1 D <br /> ACORO® CERTIFICATE OF LIABILITY INSURANCE FDA TE(MM/DD/YYYY) <br /> 2/9/2014 <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 Kimberly Rice <br /> NAME: y <br /> Hampson Mowrer Kreitz Agency PHONE (610)868-8507 FAX No: (610)868-7604 A'C <br /> 54 S. Commerce Way, Suite 150 E-MAIL <br /> ADDRE <br /> INSURERS AFFORDING COVERAGE NAIC# <br /> Bethlehem PA 18017 INSURERAAtlantic Specialty Insurance 27154 <br /> INSURED INSURER B: <br /> World Clown Association INSURERC: <br /> c/o CHD Management INSURER D: <br /> 5910 Grant Place INSURER E: <br /> Merrillville IN 46410 INSURER F: <br /> COVERAGES CERTIFICATE NUMBER:5/1/2014-5/1/2015 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 POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS <br /> GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 <br /> X COMMERCIAL GENERAL LIABILITY DAMAGE,( RENTED 100,000 <br /> PRFMISFS Fa orrurrence $ r <br /> A CLAIMS-MADE 7x L00689-05 5/1/2014 5/1/2015 MED EXP(Any one person) $ 5,000 <br /> PERSONAL&ADV INJURY $ 1,000,000 <br /> GENERAL AGGREGATE $ 2,000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 1,000,000 <br /> X POLICY PRO LOC $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT <br /> Ea accident <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS AUTOS <br /> NON-OWNED 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 LIMITS ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ <br /> OFFICER/MEMBER EXCLUDED? ❑ N/A <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) <br /> Additional Named Insured: Christopher Bays <br /> Effective Date: 12/09/2014 <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 /> Bays, Christopher ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 117 Lionel Ave <br /> Jacksonville, NC 28540 AUTHORIZED REPRESENTATIVE <br /> Timothy Goldsmith/KAR "y <br /> ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. <br /> INS025(201005).01 The ACORD name and logo are registered marks of ACORD <br />