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NJD <br />DATE (MM/DD/YYYY) <br />ACQRD,. CERTIFICATE OF LIABILITY INSURANCE 1 1/31/14 <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 <br />the certificate holder in lieu of such endorsement(s). <br />PRODUCER K & K Insurance Group, Inc. <br />NAME; SMALL COMMERCIAL UNIT <br />PHONE 877-783-1161 2'60-459-5870 <br />P.O. Box 2338 <br />Fort Wayne, In 46801 <br />1AIC, No.E AICNO' <br />ADDRESS, SCU@KANDKINSURANCE.COM <br />INSURERS) AFFORDING COVERAGE NAIC S <br />INSURER A: NATIONAL CASUALTY COMPANY 11991 <br />INSURED SAND & SAGE SPORTS CAR CLUB <br />INSURER B: <br />P.O. BOX 5135 <br />INSURER C: <br />BENTON CITY, WA 99320 <br />INSURER D: <br />INSURER E: <br />: 01AM <br />1/01/14 <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: 1729689 REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED UEL—OW 8L-OWH MED TO THE INSUREO NAMED ABOVE FOR THEPOLICY 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 />INSRI LTR <br />TYPE OF INSURANCE <br />ADDLIBUOR <br />INSR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MMA]DIYYYY <br />PO <br />MM/DD1YY <br />LIMITS <br />GENERAL LIABILITY <br />EACH OCCURRENCE 1000000 <br />PREMISES LEa occurrence 300000 <br />A <br />X COMMERCIAL GENERAL LIABILITY12 <br />CLAIMS -MADE FX7 OCCUR <br />KE00003979200 <br />: 01AM <br />1/01/14 <br />12 : 01AM <br />1/01/15 <br />MED EXP (Any one person) NONE <br />Owners & Contractors <br />PERSONAL &ADV INJURY 1000000 <br />X $100,000 E&O <br />GENERAL AGGREGATE NONE <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS-COMP/OP AGG 1000000 <br />POLICY PROJECT ILOC <br />Part Lgl Liab 1000000 <br />AUTOMOBILE <br />LIABILITY <br />Ea COMBINEDl GLF_ LIMIT <br />(BODILY INJURY (Per person) <br />ANY AUTO <br />ALL OWNED AUTOS SCHEDULED <br />AUTOS <br />IBODILY INJURY (Per accident) <br />HIRED AUTOS NON -OWNED <br />AUTOS <br />PROPERTY DAMAGE <br />aaMMI) <br />UMBRELLA LIAROCCUR <br />'EACH OCCURRENCE <br />AGGREGATE <br />EXCESS LIAR CLAIMS -MADE <br />DED 0RETENTION <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANY PROPRIETORIPARTNEPJ ❑ <br />EXEC UTIVEOFFICERIMEMBER <br />EXCLUDED? <br />(Mandatory In NH) <br />NIA <br />TORYLIMITS OTHER <br />E L. EACH ACCIDENT <br />E. L. DISEASE -EA EMPLOYEE <br />E L. DISEASE -POLICY LIMIT <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) <br />EVENT DATE: 5/17-18/14 SEE ATTACHED ADDENDUM <br />EVENT TYPE: AUTOCROSS <br />LOCATION: BOWERS FIELD AIRPORT, ELLENSBURG, WA <br />CERTIFICATE HOLDER CANCELLATION <br />JODEE PENNER <br />SAND & SAGE SPORTS CAR CLUB <br />P.O. BOX 5135 <br />BENTON CITY, WA 99320 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE EUVERED Illy <br />ACCORDANCE WITH THE POLICY PROVIS1OW. �r <br />AVTHORIZ I? <br />ACORD 25 (2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />