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USACYCL-01 MRODRIGUEZ <br />Acoira' CERTIFICATE OF LIABILITY INSURANCE <br />`.--� <br />DATEIMMI'20117Y) <br />02/2112017 <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 INSURERS), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />Fairly Consulting Group, LLC <br />1800 S. Washinggton, Suite 400 <br />Amarillo, TX 79102 <br />NACONTAME:CT Fairly Group Certificates <br />_ <br />PHONE FA% <br />INC, No, Ext): (806) 376.4761 Iwc, No):(806) 337.1859 <br />nooaEss: carts@fairlygroup.com <br />INSURERS AFFORDING COVERAGE <br />NAIC# <br />INSURER A: Lexington Insurance Company <br />19437 <br />INSURED <br />INSURER B : <br />INSURER C : <br />USA Cycling, Inc. <br />INSURER D: <br />210 USA Cycling Point, Suite 100 <br />Colorado Springs, CO 80919 <br />INSURER E <br />INSURER F : <br />COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAYBE 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 <br />TYPE OF INSURANCE <br />ADOL <br />D <br />SUER <br />MD <br />POLICY NUMBER <br />POLICY EFF <br />pp <br />POLICY EXP <br />pY1 <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 1,000,000 <br />CLAIMS -MADE X OCCUR <br />X <br />015375404 <br />12/3112016 <br />12/31/2017 <br />DAMAGE TO RENTED <br />P E ISES Ea occunence <br />1,000, <br />$ 000 <br />MED EXP (Any oneperson) <br />$ Excluded <br />PERSONAL &ADV INJURY <br />$ 1,000,000 <br />GENT <br />AGGREGATE LIMIT APPLIES PER: <br />GENERALAGGREGATE <br />$ 3,000,000 <br />POLICY JECT LOC <br />PRODUCTS-COMP/OPAGG <br />$ 2,000,000 <br />X <br />$ <br />OTHER: per Event <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea accident <br />$ <br />BODILY INJURY Per person)$ <br />ANY AUTO <br />_ <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />BODILY INJURY Per accident <br />$ <br />PROPERTY AMAGE <br />PPer acci0dent <br />$ <br />___ <br />AUTOS ONL71 Y AUTO�ONLV <br />$ <br />UMBRELLA LIAR <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LIAR <br />CLAIMS -MADE <br />DED RETENTION$ <br />S <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />PER 10 <br />STAT TE ETH- <br />ANY PROPRIETORIPARTNERIEXECUTIVE ❑ <br />�pFICEq/MEMBER EXCLUDED? <br />(Mandatory in NH) <br />NIA <br />E.L EACH ACCIDENT <br />S <br />E.L. DISEASE - EA EMPLOYE <br />$ <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE -POLICY LIMIT <br />$ <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />Job 2017-803 <br />Endorsement LEXD00O21 (LX0404) SCHEDULE OF NAMED INSUREDS: Event Organizers and/or Promoters are Named Insureds. It shall be a condition of <br />coverage that all organizers/promoters for whom coverage is afforded under this policy execute a USAC Event Permit Application and coverage will be <br />afforded only for the specific event and date on the permit. <br />The General Liability policy includes a blanket automatic additional Insured endorsement that provides additional Insured status to the certificate holder only <br />when there is a written contract between a named insured and the certificate holder that requires such status. Please see attached endorsement LX4309 <br />SEE ATTACHED ACORD 101 <br />CERTIFICATE HOLDER CANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />Cityof South Bend <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />227 West Jefferson <br />South Bend, IN 46601 <br />-- <br />AUTHORIZED REPRESENTATIVE <br />1 <br />ACORD 25 (2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />