Hylant Group 501 Congressional Blvd P.O. Box 1910 Carmel IN Phone: Fax:

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1 501 ongressional lvd P.O. ox 1910 armel IN Phone: Fax: KIWNIS ERTIFITE PKET current ertificate Packet is enclosed. Make copies as needed so you have ertificates on hand for future events. Our ertificate of Insurance Procedures will show you how to properly complete a ertificate. It is also necessary to complete the Procedures page showing a contact name and phone number for your club, as well as the event information. ll ertificates should include the name/address of your Kiwanis lub, the date of issuance, and the complete name/address of the certificate Holder. Important: escription of Operations... is blank and can only be altered as shown in 1. of the ertificate of Insurance Procedures. The insurance company has prohibited the use of dditional Insured wording by anyone/entity other than our agency. If the ertificate Holder is requesting special wording, such as dditional Insured, your club must call our office as only our office can issue the document. ny ertificate of Insurance altered without permission is immediately NULL N VOI! Lastly, please note that certificate does reference a Self Insured Retention. Note that this retention is 100% paid by Kiwanis International Headquarters. Please do not hesitate to contact our office if you have any questions. Thank you, dam Reiff ccount Manager Phone: x7179 Fax:

2 TO: KIWNIS LUS & MEMERS RE: Kiwanis International ommercial General Liability Insurance ERTIFITE OF INSURNE PROEURES Ext # Please complete your certificate(s) of insurance in the order which follows:. Enter date certificate is being issued (i.e. today s date) in the upper right hand corner.. Enter the Kiwanis lub name, contact person, and complete mailing address in the upper left of form identified as Insured.. Enter the certificate holder name, contact (if any), and complete mailing address as required by your insurance carrier in the certificate holder box at the bottom left of the form. ertificate Holder is the organization, firm or person who is requesting proof of insurance from your club.. In the description of operations section directly above the certificate holder box, please enter the type of event, the date(s) of the event, and the location where the event is being held. ny ertificate of Insurance which is altered beyond this will be considered NULL N VOI! 2. omplete and make 2 copies of the certificate. 3. Send the original ertificate to the ertificate Holder (i.e., the party requesting proof of insurance.) 4. Send a copy of the certificate along with a completed copy of this form to: HYLNT GROUP P.O. OX 1910 RMEL, IN IMPORTNT!! The attached ertificate forms cannot be modified or altered in any way without the express permission of and the Insurance ompany. If you have a certificate which requires alteration such as dditional Insured wording, please contact Hylant Group at x OMPLETE THE FOLLOWING: lub Name and ddress: ontact Name & Phone Number: Type of Event: ate(s) & Location:

3 OR PROUER PO ox 1910 armel, IN ERTIFITE OF LIILITY INSURNE TE (MM//YY) THIS ERTIFITE IS ISSUE S MTTER OF INFORMTION ONLY N ONFERS NO RIGHTS UPON THE ERTIFITE HOLER, THIS ERTIFITE OES NOT MEN, EXTEN OR LTER THE OVERGE FFORE Y THE POLIIES ELOW Phone No Fax No OMPNIES FFORING OVERGE INSURE: Kiwanis International - ll lubs & Their Members Insured Local lub: LU NME: LU RESS: Lexington Insurance ompany OVERGES THIS IS TO ERTIFY THT THE POLIIES OF INSURNE LISTE ELOW HVE EEN ISSUE TO THE INSURE NME OVE FOR THE POLIY PERIO INITE, NOTWITHSTNING NY REQUIREMENT, TERM OR ONITION OF NY ONTRT OR OTHER OUMENT WITH RESPET TO WHIH THIS ERTIFITE MY E ISSUE OR MY PERTIN, THE INSURNE FFORE Y THE POLIIES ESRIE HEREIN IS SUJET TO LL THE TERMS, EXLUSIONS N ONITIONS OF SUH POLIIES. LIMITS SHOWN MY HVE EEN REUE Y PI LIMS. O LTR TYPE OF INSURNE POLIY NUMER POLIY EFFETIVE TE (MM//YY) POLIY EXPIRTION TE (MM//YY) GENERL LIILITY GENERL GGREGTE $ 2,000,000 X OMMERIL GENERL LIILITY /01/08 11/01/09 PROUTS-OMP/OP GG $ 2,000,000 LIMS ME X OUR PERSONL&V INJURY $ 2,000,000 OWNERS&ONTRTOR S PROT EH OURRENE $ 2,000,000 X GG. PER ISTRIT FIRE MGE (ny one fire) $ 100,000 ME EXP (ny one person) $ UTOMOILE LIILITY /01/08 11/01/09 NY UTO SMPLE!! OMINE SINGLE LIMIT $ 1,000,000 LL OWNE UTOS SHEULE UTOS OILY INJURY X HIRE UTOS (Per person) $ X NON-OWNE UTOS X $3,000,000 ggregate O NOT UPLITE! PROPERTY MGE $ GRGE LIILITY UTO ONLY-E IENT $ NY UTO OTHER THN UTO ONLY $ EH IENT $ GGREGTE $ EXESS LIILITY EH OURRENE $ UMRELL FORM GGREGTE $ OTHER THN UMRELL FORM $ WORKERS OMPENSTION N W STTU- OTH- $ TORYLIMITS ER EMPLOYER S LIILITY $ EL EH IENT $ IN L THE PROPRIETORS/ EL ISESE-POLIY LIMIIT $ PRTNERS/EXEUTIVE EXL OFFIERS RE: EL ISESE-E EMPLOYEE $ Self Insured Retention /01/08 11/01/09 ll laims $ 100,000 ESRIPTION OF OPERTIONS/LOTIONS/VEHILES/SPEIL ITEMS ERTIFITE HOLER Name: ttn: ddress: OR 25-S(1/95) TM LIMITS

4 OR TM PROUER P.O. ox 1910 armel, IN ERTIFITE OF LIILITY INSURNE TE (MM//YY) THIS ERTIFITE IS ISSUE S MTTER OF INFORMTION ONLY N ONFERS NO RIGHTS UPON THE ERTIFITE HOLER, THIS ERTIFITE OES NOT MEN, EXTEN OR LTER THE OVERGE FFORE Y THE POLIIES ELOW Phone No Fax No OMPNIES FFORING OVERGE INSURE: Kiwanis International - ll lubs & Their Members Insured Local lub: LU NME: LU RESS: Lexington Insurance ompany OVERGES THIS IS TO ERTIFY THT THE POLIIES OF INSURNE LISTE ELOW HVE EEN ISSUE TO THE INSURE NME OVE FOR THE POLIY PERIO INITE, NOTWITHSTNING NY REQUIREMENT, TERM OR ONITION OF NY ONTRT OR OTHER OUMENT WITH RESPET TO WHIH THIS ERTIFITE MY E ISSUE OR MY PERTIN, THE INSURNE FFORE Y THE POLIIES ESRIE HEREIN IS SUJET TO LL THE TERMS, EXLUSIONS N ONITIONS OF SUH POLIIES. LIMITS SHOWN MY HVE EEN REUE Y PI LIMS. O LTR TYPE OF INSURNE POLIY NUMER POLIY EFFETIVE TE (MM//YY) POLIY EXPIRTION TE (MM//YY) GENERL LIILITY GENERL GGREGTE $ 2,000,000 X OMMERIL GENERL LIILITY /01/08 11/01/09 PROUTS-OMP/OP GG $ 2,000,000 LIMS ME X OUR PERSONL&V INJURY $ 2,000,000 OWNERS&ONTRTOR S PROT EH OURRENE $ 2,000,000 X GG PER ISTRIT FIRE MGE (ny one fire) $ 100,000 ME EXP (ny one person) $ UTOMOILE LIILITY NY UTO OMINE SINGLE LIMIT $ 1,000,000 LL OWNE UTOS SHEULE UTOS OILY INJURY X HIRE UTOS /01/08 11/01/09 (Per person) $ X NON-OWNE UTOS X $3,000,000 ggregate PROPERTY MGE $ GRGE LIILITY UTO ONLY-E IENT $ NY UTO OTHER THN UTO ONLY $ EH IENT $ GGREGTE $ EXESS LIILITY EH OURRENE $ UMRELL FORM GGREGTE $ OTHER THN UMRELL FORM $ WORKERS OMPENSTION N W STTU- OTH- $ TORYLIMITS ER EMPLOYER S LIILITY $ EL EH IENT $ IN L THE PROPRIETORS/ EL ISESE-POLIY LIMIIT $ PRTNERS/EXEUTIVE EXL OFFIERS RE: EL ISESE-E EMPLOYEE $ Self Insured Retention /01/08 11/01/09 ll laims $ 100,000 ESRIPTION OF OPERTIONS/LOTIONS/VEHILES/SPEIL ITEMS LIMITS ERTIFITE HOLER Name: ttn: ddress: OR 25-S(1/95)

5 KIWNIS INTERNTIONL ERTIFITE OF INSURNE REQUEST WITH ITIONL INSURE WORING PLESE OMPLETE EFORE ORERING!! We strive to meet a 24 hour turnaround ate Ordered: Kiwanis lub Name: ontact: Phone Number ontact ddress: dd l Insured Name: ttn: ddress: dd l Insured Name: ttn: ddress: Fax Number: escription of Event: Event ate(s): (Include set up/tear down) Event Location: Special Instructions: Fax or to ontact: Yes No Fax # / Fax or to dd l Insured: Yes No Fax # / PO ox 1910 armel, IN x7179 Fax: