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DocuSign Envelope ID: F6619571-9F6F-4127-B5E4-9893C398C2E6 <br /> DATE(MMIDDIYYYY) <br /> CERTIFICATE OF LIABILITY INSURANCE 109/27/20115 <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 pollcy(les) must be endorsed. If SUBROGATION IS WAIVED,$Object 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 ice <br /> NAME: � _. <br /> aT pson I4owrer Kreitz Agency PHONE . (610)868-8507 FAX IA/ Na (610)868-7604 <br /> c <br /> 54 S. Commerce Gray, Suite 1509 E-MAIL <br /> INSURER(Sj AFFORDING COVERAGE NAIC#A <br /> Bethlehem PA 1EO1°7 tlaTat�G S e�ialt lrzstar rz�e 7154 <br /> INSURED INSURER B <br /> World Clown Association INSURER C: <br /> c/o CHD Management INSURER D: <br /> 591.0 Grant Place INSURE RE: <br /> �� ` l.l,l�ral.le _ITT 4 4-109 INSUREr�F <br /> COVERAGES CERTIFICATE NU BER:GL 5/1/15 to 5/l/16 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 V\A-ITCH 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 /> LTR _ TYPE OF INSURANCE ADDL SUBR POLICY NUMBER �fNlrDDIYYYY UM DD/YYYY. LIMITS <br /> LTR <br /> GENERAL LIABILITY EACH OCCURRENCE $ 1.,4090,444 <br /> LIANIA -T RERT-ff 1001 090901 <br /> X COMMERCIAL GENERAL LIABILITY PREMISES Ea accurrenca _ <br /> A -1 CLAaMS-MAGI OccuR a gQS89-06 5/1/2015 5l1l201 6 =_D ESP`u y a e Parso a ., _ 5 K 0001' <br /> PERSONAL A AOV INJURY $ 1,,004,0940b <br /> GENERAL AGGREGATE $ 2,000,000 <br /> GEN`LAGGREGA`LE LIMIT APPLIES PER: PRODUCTS-COMPI'4OP AGO $ 1,000,()00 <br /> POLICY PRO- LOG $ <br /> COMBINED SINGLE LIMIT <br /> AUTONIOBtLE LIABILITY Ea acciden,� ;d <br /> ANY AUTO BODILY INJURY(Per Person) S <br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS AUTOS <br /> NON-OWNED PROPFR7Y DAMAGE S <br /> HIRED AUTOS AUTOS Per accidents <br /> S <br /> UMBRELLA LIAB [CLAIMSMS UR EACH OCCURRENCE S <br /> EXCESS LIAB' -MADE AGGREGATE <br /> DED RETENTION S <br /> WORKERS COMPENSATION VJC STA:l T OTH- <br /> ANCD EMPLOYERS"UABILITY YIN E L..EACH ACCIDENT <br /> Y PROPF,IETOIP,h RT tFRPrXECUTIVE '.,_._ --•-• <br /> U v " 1CFR_XCLUDEL)" N I A <br /> Ihiand_tary In ClL&y E_L..("1GEASE.-FA EIAPLOYE.E <br /> ___,. 2_ <br /> It yes,de:,c6b....undi bl ._. <br /> IESCRIPTION OF OPERATIONS below E.1- DISEASE-POLICY LIMIT S <br /> DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES (Attach ACORD 101„Additional Remarks Schedule,if more space is required) <br /> Additional. flamed. Insured.. Christopher D Bays <br /> Effective Date: 14/27/2415 <br /> CERTIFICATE:HOLDER CANCELLATION ®. <br /> SHOULD ANY OF THE ABOVE DESCROBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Bays, Christopher D <br /> 117 Lionel Avenues <br /> Jac 3tsonville, NC 28540 <br /> AUTHORIZED REPRESENTATIVE <br /> Timothy Goldsmith/I' <br /> ACORD 25(2010/05) C 1988-20910 ACORD CORPORATION. All rights reserved. <br /> INS02511'201005).0'1 The ACORD name and logo are registered marks of ACORD <br />